Provider Demographics
NPI:1114233103
Name:MEDINA, GLENDA ENET
Entity Type:Individual
Prefix:MISS
First Name:GLENDA
Middle Name:ENET
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 1:15 UNION ST SUITE 557
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840
Mailing Address - Country:US
Mailing Address - Phone:978-651-2544
Mailing Address - Fax:978-686-2954
Practice Address - Street 1:15 UNION ST STE 557
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1866
Practice Address - Country:US
Practice Address - Phone:978-651-2544
Practice Address - Fax:978-686-2954
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS888810708101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor