Healthcare Provider Details

I. General information

NPI: 1710349618
Provider Name (Legal Business Name): MIGUEL MEJIA SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 SOQUEL AVE STE 100
SANTA CRUZ CA
95062-1402
US

IV. Provider business mailing address

2250 SOQUEL AVE STE 100
SANTA CRUZ CA
95062-1402
US

V. Phone/Fax

Practice location:
  • Phone: 831-600-2800
  • Fax:
Mailing address:
  • Phone: 831-600-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: