Provider Demographics
NPI:1356017990
Name:CRITTLE, MERRI
Entity Type:Individual
Prefix:
First Name:MERRI
Middle Name:
Last Name:CRITTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W ADAMS ST STE 403
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1645
Mailing Address - Country:US
Mailing Address - Phone:904-966-9417
Mailing Address - Fax:904-341-5505
Practice Address - Street 1:630 W ADAMS ST STE 403
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1645
Practice Address - Country:US
Practice Address - Phone:904-966-9417
Practice Address - Fax:904-341-5505
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLIC-1047667101YA0400X
FL101YA0400X, 171M00000X, 222Q00000X
101YM0800X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLIC-1047667Medicaid