Provider Demographics
NPI:1588111231
Name:MERRILL-PERRY, COURTNIE
Entity type:Individual
Prefix:
First Name:COURTNIE
Middle Name:
Last Name:MERRILL-PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CASTING CT
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-5766
Mailing Address - Country:US
Mailing Address - Phone:801-625-3700
Mailing Address - Fax:
Practice Address - Street 1:8 CASTING CT
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-5766
Practice Address - Country:US
Practice Address - Phone:801-625-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10430686-35021041C0700X
174400000X
SC154321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT8760003008007Medicaid
UT000055266OtherMEDICARE PIN