Provider Demographics
NPI:1972718831
Name:MERRICK, PETER MICHAEL (MS)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MICHAEL
Last Name:MERRICK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-4828
Mailing Address - Country:US
Mailing Address - Phone:716-997-2404
Mailing Address - Fax:
Practice Address - Street 1:4086 SENECA ST
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3022
Practice Address - Country:US
Practice Address - Phone:716-674-2206
Practice Address - Fax:716-674-2415
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPENDING101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00838757Medicaid