Provider Demographics
NPI:1205009768
Name:MEDINA, ANTONIO C (MFT)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:C
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 S LAKE FOREST DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-2193
Mailing Address - Country:US
Mailing Address - Phone:469-708-7151
Mailing Address - Fax:
Practice Address - Street 1:5900 S LAKE FOREST DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-2193
Practice Address - Country:US
Practice Address - Phone:469-708-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104550101YA0400X
101YM0800X
CA49505106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health