Healthcare Provider Details

I. General information

NPI: 1336670777
Provider Name (Legal Business Name): LOURDES MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CALIFORNIA DRIVE
VACAVILLE CA
95620
US

IV. Provider business mailing address

PO BOX 95
VACAVILLE CA
95696-0095
US

V. Phone/Fax

Practice location:
  • Phone: 707-448-6841
  • Fax:
Mailing address:
  • Phone: 707-639-0037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31830
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY31830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: