Provider Demographics
NPI:1942461520
Name:MERRITT, DONNA
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:MERRITT
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:MERRITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNS, NP
Mailing Address - Street 1:1310 KINGS COVE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1671
Mailing Address - Country:US
Mailing Address - Phone:317-581-1558
Mailing Address - Fax:
Practice Address - Street 1:1310 KINGS COVE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1671
Practice Address - Country:US
Practice Address - Phone:317-581-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000074A101YP2500X
IN700000742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000607200OtherANTHEM PIN NUMBER
IN200912330Medicaid
IN2004599330AOtherMEDICAID GROUP#
IN200912330Medicaid