Healthcare Provider Details

I. General information

NPI: 1104189950
Provider Name (Legal Business Name): JULIANA MEJIA- GONZALEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 W 43RD ST STE 603
NEW YORK NY
10036-7408
US

IV. Provider business mailing address

189 MONTGOMERY ST APT 3
JERSEY CITY NJ
07302-3667
US

V. Phone/Fax

Practice location:
  • Phone: 347-661-2917
  • Fax:
Mailing address:
  • Phone: 347-661-2917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number084426-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: