Provider Demographics
NPI:1770240004
Name:MEDINA, MELISSA ISABEL (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ISABEL
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 S SAN ANTONIO ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:TX
Mailing Address - Zip Code:78573-0585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 S SAN ANTONIO ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:TX
Practice Address - Zip Code:78573-0585
Practice Address - Country:US
Practice Address - Phone:956-393-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83264101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional