Provider Demographics
NPI:1558585919
Name:MEJIA, FABIOLA I
Entity Type:Individual
Prefix:MRS
First Name:FABIOLA
Middle Name:I
Last Name:MEJIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13200 MCCORMICK DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3010
Mailing Address - Country:US
Mailing Address - Phone:813-814-5971
Mailing Address - Fax:813-814-5972
Practice Address - Street 1:13200 MCCORMICK DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3010
Practice Address - Country:US
Practice Address - Phone:813-814-5971
Practice Address - Fax:813-814-5972
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSI 13172355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013456700Medicaid