Healthcare Provider Details

I. General information

NPI: 1063784460
Provider Name (Legal Business Name): LESLIE MERRITT BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 US HIGHWAY 45 N
ELDORADO IL
62930-3766
US

IV. Provider business mailing address

1412 US HIGHWAY 45 N
ELDORADO IL
62930-3766
US

V. Phone/Fax

Practice location:
  • Phone: 618-273-3326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178002600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: