Healthcare Provider Details

I. General information

NPI: 1144564378
Provider Name (Legal Business Name): LEASA MERRILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2012
Last Update Date: 11/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 LINCOLN ST
WORCESTER MA
01605-2106
US

IV. Provider business mailing address

15A WINDSOR AVE
ACTON MA
01720-2809
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-3033
  • Fax:
Mailing address:
  • Phone: 978-429-8133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: