Provider Demographics
NPI:1629413539
Name:MEDINA, ALBA ALEJANDRA (LMFT 113496)
Entity Type:Individual
Prefix:MS
First Name:ALBA
Middle Name:ALEJANDRA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMFT 113496
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5201
Mailing Address - Country:US
Mailing Address - Phone:909-596-5921
Mailing Address - Fax:909-596-3954
Practice Address - Street 1:1350 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5201
Practice Address - Country:US
Practice Address - Phone:909-596-5921
Practice Address - Fax:909-596-3954
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINTERN 71014106H00000X
CA113496106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist