Healthcare Provider Details

I. General information

NPI: 1376984104
Provider Name (Legal Business Name): WENDY MEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 VINE ST
LOS ANGELES CA
90038-1612
US

IV. Provider business mailing address

PO BOX 226763
LOS ANGELES CA
90022-0463
US

V. Phone/Fax

Practice location:
  • Phone: 323-769-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: