Provider Demographics
NPI:1275617615
Name:MEDINA-DAVIDSON, MARTHA LIDIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:LIDIA
Last Name:MEDINA-DAVIDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N MAIN ST STE 890
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-3608
Mailing Address - Country:US
Mailing Address - Phone:949-206-4106
Mailing Address - Fax:
Practice Address - Street 1:1200 N MAIN ST
Practice Address - Street 2:890
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3640
Practice Address - Country:US
Practice Address - Phone:714-480-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA182371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical