Provider Demographics
NPI:1679284004
Name:MEDINA, LETICIA (LCSW)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:MEDINA
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 1:1300 W FLORIDA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4628
Mailing Address - Country:US
Mailing Address - Phone:951-765-0633
Mailing Address - Fax:
Practice Address - Street 1:1300 W FLORIDA AVE STE C
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4628
Practice Address - Country:US
Practice Address - Phone:951-765-0633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1105091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical