Provider Demographics
NPI:1063784460
Name:MERRITT, LESLIE (BS)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MERRITT
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 US HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1412 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3766
Practice Address - Country:US
Practice Address - Phone:618-273-3326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178002600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health