Provider Demographics
NPI:1346210499
Name:WILLERT, MERYL G (PHD)
Entity Type:Individual
Prefix:DR
First Name:MERYL
Middle Name:G
Last Name:WILLERT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-1148
Mailing Address - Country:US
Mailing Address - Phone:701-837-6508
Mailing Address - Fax:701-858-1839
Practice Address - Street 1:300 45TH ST SW
Practice Address - Street 2:SUITE 311
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1189
Practice Address - Country:US
Practice Address - Phone:701-837-6508
Practice Address - Fax:701-858-1839
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18694Medicaid
ND28565OtherBCBS - FARGO
28552OtherBCBS - MINOT
ND58569OtherBCBS - BISMARCK
ND20281773958103A002OtherTRICARE
61-28263OtherMEDICA (UBH)
28552OtherBCBS - MINOT
ND18694Medicaid