Provider Demographics
NPI:1639413537
Name:MEDINA, ERNEST JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:MEDINA
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 TAHOE CT
Mailing Address - Street 2:A
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5494
Mailing Address - Country:US
Mailing Address - Phone:254-247-4706
Mailing Address - Fax:
Practice Address - Street 1:3010 SCOTT BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-6800
Practice Address - Country:US
Practice Address - Phone:254-773-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67807101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional