Healthcare Provider Details

I. General information

NPI: 1679539191
Provider Name (Legal Business Name): KRISTINE MERRILL MSW; LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N MAIN ST SUITE 3
POYNETTE WI
53955-8963
US

IV. Provider business mailing address

415 N MAIN ST SUITE 3
POYNETTE WI
53955-8963
US

V. Phone/Fax

Practice location:
  • Phone: 608-635-2146
  • Fax:
Mailing address:
  • Phone: 608-635-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4372-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: