Provider Demographics
NPI:1366801342
Name:MERRILLS, KRISTI (LMSW)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:MERRILLS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-8525
Mailing Address - Country:US
Mailing Address - Phone:269-467-1001
Mailing Address - Fax:
Practice Address - Street 1:677 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-8525
Practice Address - Country:US
Practice Address - Phone:269-467-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087567104100000X
MI68011123321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI211708146Medicaid