Provider Demographics
NPI:1699827592
Name:MEDINA, ROSA
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34054
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91394-4054
Mailing Address - Country:US
Mailing Address - Phone:818-515-3237
Mailing Address - Fax:
Practice Address - Street 1:10605 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6342
Practice Address - Country:US
Practice Address - Phone:818-832-2400
Practice Address - Fax:818-832-6197
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW12922101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health