Provider Demographics
NPI:1407267503
Name:MEDINA, BRENDA (LICSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-1556
Mailing Address - Country:US
Mailing Address - Phone:401-500-5458
Mailing Address - Fax:401-596-2496
Practice Address - Street 1:193 CANAL ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-1556
Practice Address - Country:US
Practice Address - Phone:401-500-5458
Practice Address - Fax:401-596-2496
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW024281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical