Provider Demographics
NPI:1578279279
Name:MEDINA, SOPHIA ANNA'EI
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:ANNA'EI
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1369 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5429
Mailing Address - Country:US
Mailing Address - Phone:209-305-1786
Mailing Address - Fax:
Practice Address - Street 1:1369 ADAMS AVE
Practice Address - Street 2:APT 7314
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5429
Practice Address - Country:US
Practice Address - Phone:209-305-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician