Provider Demographics
NPI:1104558626
Name:MEZA, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:MEZA
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:PO BOX 5711
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92165-5711
Mailing Address - Country:US
Mailing Address - Phone:619-249-3167
Mailing Address - Fax:
Practice Address - Street 1:10707 JAMACHA BLVD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91978-1800
Practice Address - Country:US
Practice Address - Phone:619-249-3167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14333101YA0400X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)