Healthcare Provider Details

I. General information

NPI: 1467696567
Provider Name (Legal Business Name): GEMMA JACQUELINE MENDIETA ED.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5888 SW 27TH ST
MIAMI FL
33155-3135
US

IV. Provider business mailing address

5888 SW 27TH ST
MIAMI FL
33155-3135
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-4236
  • Fax:
Mailing address:
  • Phone: 305-662-4236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: