Healthcare Provider Details

I. General information

NPI: 1427158203
Provider Name (Legal Business Name): MIKEL M MERRITT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 MDG 221 3RD ST W
RANDOLPH AFB TX
78150
US

IV. Provider business mailing address

2729 SOCORRO LOOP APT B
HOLLOMAN AFB NM
88330-7124
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-2448
  • Fax:
Mailing address:
  • Phone: 505-572-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number682
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: