Provider Demographics
NPI:1821253642
Name:MEDINA, LILLIAN S (CASAC-T)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:S
Last Name:MEDINA
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15648 77TH ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80-20 KEW GARDENS
Practice Address - Street 2:SUITE 704
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415
Practice Address - Country:US
Practice Address - Phone:718-520-1513
Practice Address - Fax:718-520-6460
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20290101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid