Provider Demographics
NPI:1932140175
Name:MERILSON, LISA SUNDVALL (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUNDVALL
Last Name:MERILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:SUNDVALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:221 N CAUSEWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-5298
Mailing Address - Country:US
Mailing Address - Phone:386-423-0442
Mailing Address - Fax:386-423-0402
Practice Address - Street 1:221 N CAUSEWAY
Practice Address - Street 2:SUITE B
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5298
Practice Address - Country:US
Practice Address - Phone:386-423-0442
Practice Address - Fax:386-423-0402
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6889103G00000X
FLPY6889103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74094OtherBLUE CROSS BLUE SHIELD
FL7280563OtherAETNA
FL1416OtherDISABILITY DETERMINATIONS
FL74094OtherBLUE CROSS BLUE SHIELD