Provider Demographics
NPI:1083049993
Name:MEDINA, MAGALI
Entity Type:Individual
Prefix:
First Name:MAGALI
Middle Name:
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 1:6 TAKKO MACHI WAY
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-6688
Mailing Address - Country:US
Mailing Address - Phone:209-617-2554
Mailing Address - Fax:
Practice Address - Street 1:2678 MERGANSER CT
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-9473
Practice Address - Country:US
Practice Address - Phone:209-617-2554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X, 390200000X
CAASW677021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program