Provider Demographics
NPI:1871843334
Name:MEDINA'S WAY
Entity Type:Organization
Organization Name:MEDINA'S WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:NITA
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, PSYCHOTHERAPIST
Authorized Official - Phone:414-719-6633
Mailing Address - Street 1:6815 W CAPITOL AVE
Mailing Address - Street 2:#202
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216
Mailing Address - Country:US
Mailing Address - Phone:414-751-8950
Mailing Address - Fax:414-461-2005
Practice Address - Street 1:6815 W CAPITOL AVE
Practice Address - Street 2:#202
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216
Practice Address - Country:US
Practice Address - Phone:414-751-8950
Practice Address - Fax:414-461-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1423-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801069497Medicare UPIN