Provider Demographics
NPI:1295020022
Name:MEDINA, ANGELICA DEIDRE (CCSW)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:DEIDRE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:CCSW
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 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:505-296-8292
Mailing Address - Fax:
Practice Address - Street 1:2573 STATE HIGHWAY 522
Practice Address - Street 2:
Practice Address - City:QUESTA
Practice Address - State:NM
Practice Address - Zip Code:87556
Practice Address - Country:US
Practice Address - Phone:575-586-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor