Provider Demographics
NPI:1689909574
Name:MEDINA, LORI ELIZABETH (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ELIZABETH
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21141 S FORREST DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7404
Mailing Address - Country:US
Mailing Address - Phone:918-207-0810
Mailing Address - Fax:
Practice Address - Street 1:17091 S. MUSKOGEE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74465-4405
Practice Address - Country:US
Practice Address - Phone:918-458-6986
Practice Address - Fax:918-458-0499
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3261101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health