Provider Demographics
NPI:1891503777
Name:MERRIMAN, KELSIE
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:MERRIMAN
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 1:3148 DICK WILSON BLVD APT 2325
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5159
Mailing Address - Country:US
Mailing Address - Phone:717-804-7488
Mailing Address - Fax:
Practice Address - Street 1:2868 MAHAN DR UNIT 25
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5468
Practice Address - Country:US
Practice Address - Phone:850-391-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician