Provider Demographics
NPI:1427158203
Name:MERRITT, MIKEL M (PHD)
Entity type:Individual
Prefix:
First Name:MIKEL
Middle Name:M
Last Name:MERRITT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 SOCORRO LOOP APT B
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-7124
Mailing Address - Country:US
Mailing Address - Phone:505-572-5676
Mailing Address - Fax:
Practice Address - Street 1:359 MDG
Practice Address - Street 2:221 3RD ST W
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150
Practice Address - Country:US
Practice Address - Phone:210-652-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE682103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical