Healthcare Provider Details

I. General information

NPI: 1912583592
Provider Name (Legal Business Name): GABRIELLE MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CONCOURS STE 4102
ONTARIO CA
91764-6564
US

IV. Provider business mailing address

13500 LIVE OAK ST APT 53
HESPERIA CA
92345-0503
US

V. Phone/Fax

Practice location:
  • Phone: 909-240-1764
  • Fax: 909-259-2369
Mailing address:
  • Phone: 323-314-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: