Provider Demographics
NPI:1275007353
Name:MEDINA, DONNA ELIZABETH (LADC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:ELIZABETH
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-2340
Mailing Address - Country:US
Mailing Address - Phone:860-691-0873
Mailing Address - Fax:
Practice Address - Street 1:30 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-2340
Practice Address - Country:US
Practice Address - Phone:860-691-0873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)