Healthcare Provider Details

I. General information

NPI: 1578285474
Provider Name (Legal Business Name): GANESSA MEJIAS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GANESSA MEJIAS GANESSA MEJIAS

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 CENTRAL AVE
NORTHFIELD IL
60093-3006
US

IV. Provider business mailing address

10638 S BENSLEY AVE
CHICAGO IL
60617-6130
US

V. Phone/Fax

Practice location:
  • Phone: 773-474-2537
  • Fax:
Mailing address:
  • Phone: 773-474-2537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: