Provider Demographics
NPI:1417970245
Name:MERILLAT, RICHARD L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:MERILLAT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 SE 47TH ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-9661
Mailing Address - Country:US
Mailing Address - Phone:239-829-5480
Mailing Address - Fax:
Practice Address - Street 1:1222 SE 47TH ST
Practice Address - Street 2:SUITE 217
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9661
Practice Address - Country:US
Practice Address - Phone:239-829-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW71001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767529100Medicaid