Healthcare Provider Details

I. General information

NPI: 1629350277
Provider Name (Legal Business Name): EVELYN MIREA MEJIA MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N DELAWARE ST
SAN MATEO CA
94401-1732
US

IV. Provider business mailing address

173 SANTA LUCIA AVE APT 5
SAN BRUNO CA
94066-5251
US

V. Phone/Fax

Practice location:
  • Phone: 650-294-0753
  • Fax:
Mailing address:
  • Phone: 415-867-0237
  • Fax: 415-867-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: