Healthcare Provider Details

I. General information

NPI: 1700241593
Provider Name (Legal Business Name): MISTY JO MEJIA CADCII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 FIRST ST
COACHELLA CA
92236-1407
US

IV. Provider business mailing address

1830 BRADLEY ST
RIVERSIDE CA
92504-5435
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-9000
  • Fax:
Mailing address:
  • Phone: 909-725-4714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: