Provider Demographics
NPI:1760521629
Name:MERCHANT, MUNIRA
Entity Type:Individual
Prefix:
First Name:MUNIRA
Middle Name:
Last Name:MERCHANT
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 1:479 MAYFIELD LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-3287
Mailing Address - Country:US
Mailing Address - Phone:630-650-1515
Mailing Address - Fax:
Practice Address - Street 1:1079 E WILSON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2479
Practice Address - Country:US
Practice Address - Phone:630-650-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0050831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232153OtherBCBS
IL202414Medicare ID - Type Unspecified