Provider Demographics
NPI:1902010572
Name:MEDINA, EDWARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LINDA PL
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-1632
Mailing Address - Country:US
Mailing Address - Phone:914-734-2163
Mailing Address - Fax:
Practice Address - Street 1:3302 STEUBEN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2806
Practice Address - Country:US
Practice Address - Phone:718-920-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0378671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical