1396367736 NPI number — DR. LAURA GENELLE MEZA VALENCIA PSYD

Table of content: DR. LAURA GENELLE MEZA VALENCIA PSYD (NPI 1396367736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396367736 NPI number — DR. LAURA GENELLE MEZA VALENCIA PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEZA VALENCIA
Provider First Name:
LAURA
Provider Middle Name:
GENELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396367736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2436 N FEDERAL HWY # 185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIGHTHOUSE POINT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33064-6854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-465-4962
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE MIFFLIN PLACE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02138-4946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-465-4962
Provider Business Practice Location Address Fax Number:
888-965-2499
Provider Enumeration Date:
05/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY10765 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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