Provider Demographics
NPI:1760920219
Name:MERRITT, MYESHA
Entity Type:Individual
Prefix:
First Name:MYESHA
Middle Name:
Last Name:MERRITT
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 1:2632 BERMUDA LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2392
Mailing Address - Country:US
Mailing Address - Phone:813-489-4547
Mailing Address - Fax:813-381-5140
Practice Address - Street 1:1463 OAKFIELD DR
Practice Address - Street 2:SUITE 117
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-3899
Practice Address - Country:US
Practice Address - Phone:813-489-4547
Practice Address - Fax:813-381-5140
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty