Basic Information
| Provider Information | |||||||||
| NPI: | 1215563804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERINO | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | OSWALDO | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 38 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205623323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 291 W. CASA BLANCA RD. BLDG. # 7 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205623323 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2020 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LAC-18476 | AZ | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.