Healthcare Provider Details

I. General information

NPI: 1639295801
Provider Name (Legal Business Name): GUSTAVO BERNARDO MEJIA MA, LPC, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 GRAND AVE 3RD FLOOR
ENGLEWOOD NJ
07631-3572
US

IV. Provider business mailing address

150 TRYON AVE APT E1
ENGLEWOOD NJ
07631-1670
US

V. Phone/Fax

Practice location:
  • Phone: 201-245-1159
  • Fax: 201-541-8100
Mailing address:
  • Phone: 201-245-1159
  • Fax: 201-541-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00396500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00170800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: