Healthcare Provider Details

I. General information

NPI: 1346776093
Provider Name (Legal Business Name): PATRICIA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE BUILDING B
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

2413 WALKER WOODS CT NW
GRAND RAPIDS MI
49544-1489
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-3001
  • Fax:
Mailing address:
  • Phone: 616-366-7475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: