Healthcare Provider Details

I. General information

NPI: 1104459973
Provider Name (Legal Business Name): INGRID ROXANA MEJIA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: INGRID ROXANA MEJIA DE MORENO

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 10/04/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7231 W HESS AVE
PHOENIX AZ
85043-7528
US

IV. Provider business mailing address

7231 W HESS AVE
PHOENIX AZ
85043-7528
US

V. Phone/Fax

Practice location:
  • Phone: 623-414-9488
  • Fax:
Mailing address:
  • Phone: 623-414-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number107494
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16752
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: