Provider Demographics
NPI:1871059030
Name:EDWARD MERKLE
Entity type:Organization
Organization Name:EDWARD MERKLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MERKLE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:386-416-9767
Mailing Address - Street 1:313 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-2618
Mailing Address - Country:US
Mailing Address - Phone:386-416-9767
Mailing Address - Fax:
Practice Address - Street 1:4770 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4544
Practice Address - Country:US
Practice Address - Phone:386-416-9767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD MERKLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-13
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1295077212Medicaid