Healthcare Provider Details

I. General information

NPI: 1215635768
Provider Name (Legal Business Name): GLADYS ELIZABETH MEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 04/30/2024
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 W 105TH ST
LOS ANGELES CA
90044-4423
US

IV. Provider business mailing address

8605 SANTA MONICA BLVD # 264936
WEST HOLLYWOOD CA
90069-4109
US

V. Phone/Fax

Practice location:
  • Phone: 323-424-2693
  • Fax:
Mailing address:
  • Phone: 310-299-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number21-155540
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: