Provider Demographics
NPI:1780017129
Name:MEDINA, LOURDES E (LMFT)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:E
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 580733
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-0013
Mailing Address - Country:US
Mailing Address - Phone:209-915-9021
Mailing Address - Fax:
Practice Address - Street 1:8325 SUMMER SUNSET DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-5362
Practice Address - Country:US
Practice Address - Phone:209-915-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111326101YM0800X
CAIMF74888106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist