Healthcare Provider Details

I. General information

NPI: 1730836578
Provider Name (Legal Business Name): GUSTAVO A MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S ROYAL POINCIANA BLVD STE 300
MIAMI SPRINGS FL
33166-6667
US

IV. Provider business mailing address

3800 W BROWARD BLVD STE 100
FT LAUDERDALE FL
33312-1018
US

V. Phone/Fax

Practice location:
  • Phone: 305-892-4600
  • Fax:
Mailing address:
  • Phone: 954-587-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH20294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: