Provider Demographics
NPI:1609292069
Name:MEDINA, MINDIE A (BA)
Entity Type:Individual
Prefix:
First Name:MINDIE
Middle Name:A
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:MINDIE
Other - Middle Name:A
Other - Last Name:CLARNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2190 DELTA WATERS RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4906
Mailing Address - Country:US
Mailing Address - Phone:702-420-9219
Mailing Address - Fax:
Practice Address - Street 1:1005 E. MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:702-420-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health