Provider Demographics
NPI:1235488644
Name:MEZA, MARISOL MELANIE (EDS)
Entity Type:Individual
Prefix:MS
First Name:MARISOL
Middle Name:MELANIE
Last Name:MEZA
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-3406
Mailing Address - Country:US
Mailing Address - Phone:201-937-6704
Mailing Address - Fax:
Practice Address - Street 1:7 NELSON AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-3406
Practice Address - Country:US
Practice Address - Phone:201-937-6704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FI00165000106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist