Provider Demographics
NPI:1073126165
Name:MEDINA, ALICIA BEATRIZ
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:BEATRIZ
Last Name:MEDINA
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 1:18501 GALE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1359
Mailing Address - Country:US
Mailing Address - Phone:626-626-4997
Mailing Address - Fax:
Practice Address - Street 1:18501 GALE AVE STE 100
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1359
Practice Address - Country:US
Practice Address - Phone:626-626-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119570106H00000X
CAAMFT119570106H00000X
CALMFT142327106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist