Provider Demographics
NPI:1588174932
Name:MERRICK, MARK DUANE (LMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DUANE
Last Name:MERRICK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 822
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-0822
Mailing Address - Country:US
Mailing Address - Phone:541-839-2220
Mailing Address - Fax:
Practice Address - Street 1:3238 GAZLEY RD
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-9419
Practice Address - Country:US
Practice Address - Phone:541-839-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT80920101YM0800X
ORT1064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT80920OtherLMFT
ORT1064OtherLMFT