Provider Demographics
NPI:1790364065
Name:MEDINA, ATHENA M
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:M
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 1:1410 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2503
Mailing Address - Country:US
Mailing Address - Phone:650-373-0777
Mailing Address - Fax:
Practice Address - Street 1:24301 SOUTHLAND DR STE 510
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-1540
Practice Address - Country:US
Practice Address - Phone:925-915-0610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician