Provider Demographics
NPI:1629412085
Name:MERRELL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MERRELL
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 1:620 NW 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4034
Mailing Address - Country:US
Mailing Address - Phone:352-376-8788
Mailing Address - Fax:352-376-7901
Practice Address - Street 1:620 NW 16TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4034
Practice Address - Country:US
Practice Address - Phone:352-376-8788
Practice Address - Fax:352-376-7901
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical