Healthcare Provider Details

I. General information

NPI: 1477258192
Provider Name (Legal Business Name): LISSETTE MARI MEJIAS I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8169 CALLE CONCORDIA COND. SAN VICENTE STE. 412
PONCE PR
00717
US

IV. Provider business mailing address

8169 CALLE CONCORDIA COND. SAN VICENTE STE. 412
PONCE PR
00717
US

V. Phone/Fax

Practice location:
  • Phone: 787-284-5844
  • Fax:
Mailing address:
  • Phone: 787-284-5844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number9086
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: