Provider Demographics
NPI:1679539191
Name:MERRILL, KRISTINE (MSW; LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:MSW; LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:POYNETTE
Mailing Address - State:WI
Mailing Address - Zip Code:53955-8963
Mailing Address - Country:US
Mailing Address - Phone:608-635-2146
Mailing Address - Fax:
Practice Address - Street 1:415 N MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:POYNETTE
Practice Address - State:WI
Practice Address - Zip Code:53955-8963
Practice Address - Country:US
Practice Address - Phone:608-635-2146
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4372-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health