Provider Demographics
NPI:1710435615
Name:MEDINA, AGNIESZKA (LCSW)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AGNIESZKA
Other - Middle Name:
Other - Last Name:OSTASZEWSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:17242 SUNDERLAND DR
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2357
Mailing Address - Country:US
Mailing Address - Phone:818-309-7260
Mailing Address - Fax:818-739-5690
Practice Address - Street 1:17242 SUNDERLAND DR
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-2357
Practice Address - Country:US
Practice Address - Phone:818-309-7260
Practice Address - Fax:818-739-5690
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 202341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical