Healthcare Provider Details

I. General information

NPI: 1336740471
Provider Name (Legal Business Name): MELISSA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7254 BLANCO RD
SAN ANTONIO TX
78216-4990
US

IV. Provider business mailing address

7254 BLANCO RD
SAN ANTONIO TX
78216-4990
US

V. Phone/Fax

Practice location:
  • Phone: 210-530-1180
  • Fax:
Mailing address:
  • Phone: 210-530-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number72089
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: