Healthcare Provider Details

I. General information

NPI: 1871059030
Provider Name (Legal Business Name): EDWARD MERKLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 S RIDGEWOOD AVE
PORT ORANGE FL
32127-4544
US

IV. Provider business mailing address

313 CEDAR AVE
NEW SMYRNA BEACH FL
32169-2618
US

V. Phone/Fax

Practice location:
  • Phone: 386-416-9767
  • Fax:
Mailing address:
  • Phone: 386-416-9767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: EDWARD MERKLE
Title or Position: PRESIDENT
Credential: LMHC
Phone: 386-416-9767