Provider Demographics
NPI:1073162145
Name:MEDINA, MARY ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E 96TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3847
Mailing Address - Country:US
Mailing Address - Phone:646-331-9025
Mailing Address - Fax:
Practice Address - Street 1:1136 CASTLE HILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4801
Practice Address - Country:US
Practice Address - Phone:718-239-0395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0320841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical