Basic Information
| Provider Information | |||||||||
| NPI: | 1588111231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERRILL-PERRY | ||||||||
| FirstName: | COURTNIE | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8 CASTING CT | ||||||||
| Address2: | |||||||||
| City: | TAYLORS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296875766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016253700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 CASTING CT | ||||||||
| Address2: | |||||||||
| City: | TAYLORS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296875766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016253700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2016 | ||||||||
| LastUpdateDate: | 10/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 10430686-3502 | UT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 174400000X | N | Other Service Providers | Specialist | 1041C0700X | 15432 | SC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 260022408 | 01 | UT | RAILROAD MEDICARE | OTHER | 8760003008007 | 05 | UT | MEDICAID | 000055266 | 01 | UT | MEDICARE PIN | OTHER |