Healthcare Provider Details

I. General information

NPI: 1629127493
Provider Name (Legal Business Name): MARIANNA JANE GABRIEL MEJIA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 HIDDEN VALLEY RD
SOQUEL CA
95073-9708
US

IV. Provider business mailing address

1009 HIDDEN VALLEY RD
SOQUEL CA
95073-9708
US

V. Phone/Fax

Practice location:
  • Phone: 831-477-2818
  • Fax: 831-477-2818
Mailing address:
  • Phone: 831-477-2818
  • Fax: 831-477-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberMFC22200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: