Provider Demographics
NPI:1053078881
Name:MEDINA, CHRISTIAN OMAR (CDCA PRE)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:OMAR
Last Name:MEDINA
Suffix:
Gender:M
Credentials:CDCA PRE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1613
Mailing Address - Country:US
Mailing Address - Phone:216-459-1222
Mailing Address - Fax:216-459-2696
Practice Address - Street 1:2202 PRAME AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1626
Practice Address - Country:US
Practice Address - Phone:216-459-1222
Practice Address - Fax:216-459-2696
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH178991101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)