Provider Demographics
NPI:1053651570
Name:MERRICK, LESLIE
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:MERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:MERRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSW
Mailing Address - Street 1:745 E 300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2256
Mailing Address - Country:US
Mailing Address - Phone:801-428-1301
Mailing Address - Fax:
Practice Address - Street 1:745 E 300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2256
Practice Address - Country:US
Practice Address - Phone:801-428-1301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20036635021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical