Basic Information
Provider Information
NPI: 1033556949
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MERRIFIELD
FirstName: GRACE
MiddleName: ELANE
NamePrefix:  
NameSuffix:  
Credential:  
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Mailing Information
Address1: 1817 S 7TH ST APT 1
Address2:  
City: WACO
State: TX
PostalCode: 767062430
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2708 NE 14TH ST
Address2:  
City: POMPANO BEACH
State: FL
PostalCode: 330623565
CountryCode: US
TelephoneNumber: 8888809270
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/31/2013
LastUpdateDate: 05/31/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
222Q00000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist 

No ID Information.


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