Provider Demographics
NPI:1104224971
Name:MEJIA, GLORIA ELIZAVETTE
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:ELIZAVETTE
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 1:780 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-1003
Mailing Address - Country:US
Mailing Address - Phone:909-763-4760
Mailing Address - Fax:
Practice Address - Street 1:401 S TUSTIN ST BLDG D
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2550
Practice Address - Country:US
Practice Address - Phone:714-289-3936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111642106H00000X
CA93069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist