Provider Demographics
NPI:1710227004
Name:MEDINA, ANDREA ROSEMARY
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROSEMARY
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 266
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:CA
Mailing Address - Zip Code:95625-0266
Mailing Address - Country:US
Mailing Address - Phone:707-365-2847
Mailing Address - Fax:
Practice Address - Street 1:714 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6410
Practice Address - Country:US
Practice Address - Phone:530-477-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 67037106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist