Provider Demographics
NPI:1225617418
Name:MEDINA, ANGELA RAE (LCPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RAE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388750
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8750
Mailing Address - Country:US
Mailing Address - Phone:773-266-7621
Mailing Address - Fax:
Practice Address - Street 1:2456 W 38TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1008
Practice Address - Country:US
Practice Address - Phone:773-823-7743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health