Provider Demographics
NPI:1619096351
Name:MEDINA, CARLO DOMINIC FLOREZA (MSW)
Entity Type:Individual
Prefix:
First Name:CARLO DOMINIC
Middle Name:FLOREZA
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1995
Mailing Address - Country:US
Mailing Address - Phone:949-574-3364
Mailing Address - Fax:
Practice Address - Street 1:301 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1995
Practice Address - Country:US
Practice Address - Phone:949-574-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW817991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical