Provider Demographics
NPI:1114551330
Name:MEDINA, SUMMER DAWN (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUMMER
Middle Name:DAWN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 KERNER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4840
Mailing Address - Country:US
Mailing Address - Phone:415-473-2305
Mailing Address - Fax:415-473-3787
Practice Address - Street 1:3270 KERNER BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4840
Practice Address - Country:US
Practice Address - Phone:415-473-2305
Practice Address - Fax:415-473-3787
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health