Provider Demographics
NPI:1376103952
Name:MERRITT, GINA RAE (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:RAE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 4TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2049
Mailing Address - Country:US
Mailing Address - Phone:760-715-4977
Mailing Address - Fax:
Practice Address - Street 1:108 E HERSEY ST # 2A
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1363
Practice Address - Country:US
Practice Address - Phone:760-715-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21587225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty