Provider Demographics
NPI:1710873302
Name:MEDINA, VIDA ESPERANSA I
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:ESPERANSA
Last Name:MEDINA
Suffix:I
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 1:5800 HARPER DR NE APT 1204
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3505
Mailing Address - Country:US
Mailing Address - Phone:505-690-9517
Mailing Address - Fax:
Practice Address - Street 1:5800 HARPER DR NE APT 1204
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3505
Practice Address - Country:US
Practice Address - Phone:505-690-9517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician