Provider Demographics
NPI:1144425844
Name:MEDINA, ELISA MCKAY (MSW)
Entity Type:Individual
Prefix:MS
First Name:ELISA
Middle Name:MCKAY
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 1:8319 JORDAN VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5800
Mailing Address - Country:US
Mailing Address - Phone:301-668-5361
Mailing Address - Fax:
Practice Address - Street 1:286 MONTEVUE LN
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-8212
Practice Address - Country:US
Practice Address - Phone:240-215-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD079441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical