Healthcare Provider Details

I. General information

NPI: 1356914436
Provider Name (Legal Business Name): YANCY MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 SHERIDAN STREET #210
HOLLYWOOD FL
33026
US

IV. Provider business mailing address

11011 SHERIDAN STREET #210
HOLLYWOOD FL
33026
US

V. Phone/Fax

Practice location:
  • Phone: 954-552-6668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: