Provider Demographics
NPI:1770028110
Name:MERRITT, TYISHA
Entity Type:Individual
Prefix:
First Name:TYISHA
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 1:1034 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-3225
Mailing Address - Country:US
Mailing Address - Phone:925-681-4450
Mailing Address - Fax:925-646-5365
Practice Address - Street 1:1034 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-3225
Practice Address - Country:US
Practice Address - Phone:925-681-4450
Practice Address - Fax:925-646-5365
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health