Provider Demographics
NPI:1033597893
Name:MEDINA, SASHAANN
Entity Type:Individual
Prefix:
First Name:SASHAANN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SASHA
Other - Middle Name:
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17 NORWELL ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-2109
Mailing Address - Country:US
Mailing Address - Phone:857-919-3809
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD STE 2
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3132
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1033597893Medicare UPIN
MA1033597893Medicare PIN
MA1033597893Medicare Oscar/Certification
MA1033597893Medicare NSC