Provider Demographics
NPI:1427299577
Name:MERRY, LAURA L (LCSW, C-SWHC, BCD)
Entity type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:L
Last Name:MERRY
Suffix:
Gender:F
Credentials:LCSW, C-SWHC, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5841
Mailing Address - Country:US
Mailing Address - Phone:386-755-3016
Mailing Address - Fax:386-754-7391
Practice Address - Street 1:618 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5841
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-754-7391
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150009201104100000X
IL149.0146041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker