Healthcare Provider Details

I. General information

NPI: 1639747967
Provider Name (Legal Business Name): NILSON MEJIA LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 JOHNSON AVE STE 212
BRONX NY
10463-3539
US

IV. Provider business mailing address

3265 JOHNSON AVE STE 212
BRONX NY
10463-3539
US

V. Phone/Fax

Practice location:
  • Phone: 347-213-9592
  • Fax:
Mailing address:
  • Phone: 347-213-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number011671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: