Provider Demographics
NPI:1760886121
Name:MEDINA, DIANA (PHD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 50384
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85076-0384
Mailing Address - Country:US
Mailing Address - Phone:602-796-7081
Mailing Address - Fax:
Practice Address - Street 1:11011 S 48TH ST STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-1788
Practice Address - Country:US
Practice Address - Phone:602-900-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling