Healthcare Provider Details

I. General information

NPI: 1700325891
Provider Name (Legal Business Name): MA CHRISTINA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIA CHRISTINA MEJIA

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15029 VISTA VW
LAKE ELSINORE CA
92530-7214
US

IV. Provider business mailing address

15029 VISTA VW
LAKE ELSINORE CA
92530-7214
US

V. Phone/Fax

Practice location:
  • Phone: 719-502-5928
  • Fax:
Mailing address:
  • Phone: 719-502-5928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75072
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: