Provider Demographics
NPI:1770193567
Name:MEDINA, ARISSA MARIA
Entity Type:Individual
Prefix:
First Name:ARISSA
Middle Name:MARIA
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 1:12001 SPARTAN LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-9070
Mailing Address - Country:US
Mailing Address - Phone:909-376-2166
Mailing Address - Fax:
Practice Address - Street 1:4688 ONTARIO MILLS PKWY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5104
Practice Address - Country:US
Practice Address - Phone:909-476-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician