Provider Demographics
NPI:1487373437
Name:MERRICK, KRISTI DALE (LAC)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:DALE
Last Name:MERRICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 WR STEPHENS DR
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-5067
Mailing Address - Country:US
Mailing Address - Phone:501-605-3562
Mailing Address - Fax:
Practice Address - Street 1:12406 HIGHWAY 5 STE C
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7657
Practice Address - Country:US
Practice Address - Phone:501-781-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2208001101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional