Healthcare Provider Details

I. General information

NPI: 1225673163
Provider Name (Legal Business Name): STEPHANIE MARIE MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 THE ALAMEDA STE 425
SAN JOSE CA
95126-1453
US

IV. Provider business mailing address

3425 COFFEE RD STE C2
MODESTO CA
95355-1582
US

V. Phone/Fax

Practice location:
  • Phone: 510-679-3545
  • Fax: 510-679-3547
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: