Provider Demographics
NPI:1659088219
Name:MEJIA, GEORGINA
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
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 1:12700 VAN NUYS BLVD APT 300
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1625
Mailing Address - Country:US
Mailing Address - Phone:818-671-8869
Mailing Address - Fax:
Practice Address - Street 1:17000 VENTURA BLVD STE 100B
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4109
Practice Address - Country:US
Practice Address - Phone:818-302-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82610225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist