Provider Demographics
NPI:1851507321
Name:MEJIA, MATTHEW T (PSY D, LPC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:T
Last Name:MEJIA
Suffix:
Gender:M
Credentials:PSY D, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-7871
Mailing Address - Fax:719-543-0171
Practice Address - Street 1:300 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2006
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-0171
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0003759103T00000X
CO0003759103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02954761Medicaid