Provider Demographics
NPI:1235499138
Name:MERRILL, J. TYSON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:J. TYSON
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 ROAT ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2739
Mailing Address - Country:US
Mailing Address - Phone:607-279-1588
Mailing Address - Fax:
Practice Address - Street 1:313 ROAT ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2739
Practice Address - Country:US
Practice Address - Phone:607-279-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017082103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical