Provider Demographics
NPI:1285642918
Name:MEDINA, SERGIO (LPC)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 GATEWAY BLVD W STE 501
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3319
Mailing Address - Country:US
Mailing Address - Phone:915-772-1829
Mailing Address - Fax:915-772-5133
Practice Address - Street 1:5959 GATEWAY BLVD W STE 501
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3319
Practice Address - Country:US
Practice Address - Phone:915-772-1829
Practice Address - Fax:915-772-5133
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10517101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional