Healthcare Provider Details

I. General information

NPI: 1417972753
Provider Name (Legal Business Name): ANDREA MARIE MERRELL-WOODS LCSW-BACS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 76, BOX 4544
MISAWA APO AP
96319-0024
JP

IV. Provider business mailing address

PSC 76, BOX 4544
MISAWA APO AP
96319-0024
JP

V. Phone/Fax

Practice location:
  • Phone: 315-226-9039
  • Fax:
Mailing address:
  • Phone: 315-226-9039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4327
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: