Healthcare Provider Details

I. General information

NPI: 1558641480
Provider Name (Legal Business Name): LAURA MEJIA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 SE CENTRAL PKWY
STUART FL
34994-3984
US

IV. Provider business mailing address

1635 SW SILVER PINE WAY 109-C2
PALM CITY FL
34990-4732
US

V. Phone/Fax

Practice location:
  • Phone: 772-631-2400
  • Fax:
Mailing address:
  • Phone: 772-631-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA57955
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: