Provider Demographics
NPI:1225664303
Name:MERRY, MARIELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:
Last Name:MERRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 6TH AVE SE APT 1
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6662
Mailing Address - Country:US
Mailing Address - Phone:507-271-9589
Mailing Address - Fax:
Practice Address - Street 1:1542 ASSISI DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2777
Practice Address - Country:US
Practice Address - Phone:507-512-2062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN256831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical