Provider Demographics
NPI:1669833075
Name:MEDELLIN, ELISA (LPC)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:MEDELLIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-450-6440
Mailing Address - Fax:
Practice Address - Street 1:7526 LOUIS PASTEUR DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4001
Practice Address - Country:US
Practice Address - Phone:210-450-6440
Practice Address - Fax:210-450-2104
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354918001Medicaid
TX354918002OtherCSHCN