Healthcare Provider Details

I. General information

NPI: 1790974566
Provider Name (Legal Business Name): LINDA E MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LINDA E BLOOMQUIST

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 TEE VIEW CT
MANORVILLE NY
11949-2939
US

IV. Provider business mailing address

5 TEE VIEW CT
MANORVILLE NY
11949-2939
US

V. Phone/Fax

Practice location:
  • Phone: 631-874-3032
  • Fax: 631-874-4105
Mailing address:
  • Phone: 631-874-3032
  • Fax: 631-874-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number010311-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: