Provider Demographics
NPI:1972266815
Name:MERINO, ALISA
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:MERINO
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 1:740 E WARM SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6420
Mailing Address - Country:US
Mailing Address - Phone:208-343-7797
Mailing Address - Fax:
Practice Address - Street 1:740 E WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6420
Practice Address - Country:US
Practice Address - Phone:208-343-7813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID41118101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002269500Medicaid
ID88567OtherBLUE CROSS
ID00010006259OtherREGENCE BLUE SHIELD