Provider Demographics
NPI:1215635768
Name:MEZA, GLADYS ELIZABETH
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:ELIZABETH
Last Name:MEZA
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 1:8605 SANTA MONICA BLVD # 264936
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4109
Mailing Address - Country:US
Mailing Address - Phone:310-299-5982
Mailing Address - Fax:
Practice Address - Street 1:529 W 105TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4423
Practice Address - Country:US
Practice Address - Phone:323-424-2693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
21-155540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician