Healthcare Provider Details

I. General information

NPI: 1255070454
Provider Name (Legal Business Name): PACHAMAMA THERAPY COLLECTIVE, A PSYCHOLOGICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 P ST STE 106
SACRAMENTO CA
95811-5225
US

IV. Provider business mailing address

2958 RIVERSIDE BLVD
SACRAMENTO CA
95818-3762
US

V. Phone/Fax

Practice location:
  • Phone: 916-287-1625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. IVONNE MEJIA
Title or Position: OWNER/CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 916-287-1625