Provider Demographics
NPI:1972648855
Name:MEJIA, IVAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:MEJIA
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6666 HARWIN DR STE 158
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-2546
Mailing Address - Country:US
Mailing Address - Phone:713-429-1176
Mailing Address - Fax:832-252-9263
Practice Address - Street 1:6666 HARWIN DR STE 158
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-2546
Practice Address - Country:US
Practice Address - Phone:713-429-1176
Practice Address - Fax:832-252-9263
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102518235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183948201Medicaid