Provider Demographics
NPI:1376555805
Name:MEDINA, LESLIE (MA, MFT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9343 TECH CENTER DR FL 2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2563
Mailing Address - Country:US
Mailing Address - Phone:916-388-6374
Mailing Address - Fax:916-388-6434
Practice Address - Street 1:9343 TECH CENTER DR FL 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2563
Practice Address - Country:US
Practice Address - Phone:916-388-6374
Practice Address - Fax:916-649-7158
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist