Provider Demographics
NPI:1649765074
Name:MEDINA-PEREZ, NELIDA (LCSW)
Entity Type:Individual
Prefix:
First Name:NELIDA
Middle Name:
Last Name:MEDINA-PEREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10845 COUNTY ROAD 429
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-3813
Mailing Address - Country:US
Mailing Address - Phone:903-714-4991
Mailing Address - Fax:
Practice Address - Street 1:10845 COUNTY ROAD 429
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-3813
Practice Address - Country:US
Practice Address - Phone:903-714-4991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX598631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical