Provider Demographics
NPI:1730836578
Name:MEJIA, GUSTAVO A
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:MEJIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 W BROWARD BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1018
Mailing Address - Country:US
Mailing Address - Phone:954-587-1008
Mailing Address - Fax:
Practice Address - Street 1:700 S ROYAL POINCIANA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-6667
Practice Address - Country:US
Practice Address - Phone:305-892-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health