Provider Demographics
NPI:1346598281
Name:MEDINA, MARISOL (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25975 NORMANDIE AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3416
Mailing Address - Country:US
Mailing Address - Phone:424-251-7792
Mailing Address - Fax:
Practice Address - Street 1:25975 NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3416
Practice Address - Country:US
Practice Address - Phone:424-251-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73373282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital