Healthcare Provider Details

I. General information

NPI: 1801115506
Provider Name (Legal Business Name): MRS. MARISOL MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 OBISPO AVE
ORLANDO FL
32807-1627
US

IV. Provider business mailing address

535 OBISPO AVE
ORLANDO FL
32807-1627
US

V. Phone/Fax

Practice location:
  • Phone: 407-435-6567
  • Fax:
Mailing address:
  • Phone: 407-435-6567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 10409
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: