Provider Demographics
NPI:1619204096
Name:MEDINA, MONICA (BA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 CANEHILL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1620
Mailing Address - Country:US
Mailing Address - Phone:714-871-5646
Mailing Address - Fax:
Practice Address - Street 1:505 N EUCLID ST STE 300
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5514
Practice Address - Country:US
Practice Address - Phone:714-871-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health