Provider Demographics
NPI:1043511652
Name:MEDINA, MILLIE (LMSW)
Entity Type:Individual
Prefix:
First Name:MILLIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 YALE ST
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-1024
Mailing Address - Country:US
Mailing Address - Phone:516-812-7988
Mailing Address - Fax:
Practice Address - Street 1:344 FULTON AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550
Practice Address - Country:UM
Practice Address - Phone:516-538-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY070786-1OtherLICENSED NUMBER