Provider Demographics
NPI:1629146386
Name:MERRILL, MICHAEL H (PHD, LCPC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
Last Name:MERRILL
Suffix:
Gender:M
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E DELAWARE PL
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4962
Mailing Address - Country:US
Mailing Address - Phone:312-944-6425
Mailing Address - Fax:312-944-6452
Practice Address - Street 1:1 E DELAWARE PL
Practice Address - Street 2:SUITE 304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4962
Practice Address - Country:US
Practice Address - Phone:312-944-6425
Practice Address - Fax:312-944-6452
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TB0200X, 103TH0004X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional