Healthcare Provider Details

I. General information

NPI: 1851507321
Provider Name (Legal Business Name): MATTHEW T MEJIA PSY D, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COLORADO AVE
PUEBLO CO
81004-2006
US

IV. Provider business mailing address

110 E ROUTT AVE
PUEBLO CO
81004-2117
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8711
  • Fax: 719-543-0171
Mailing address:
  • Phone: 719-543-7871
  • Fax: 719-543-0171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY.0003759
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: