Provider Demographics
NPI:1912558370
Name:MEDINA SOTELO, MARCO ANTONIO
Entity Type:Individual
Prefix:MR
First Name:MARCO
Middle Name:ANTONIO
Last Name:MEDINA SOTELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 23RD AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144
Mailing Address - Country:US
Mailing Address - Phone:206-219-5980
Mailing Address - Fax:206-812-6161
Practice Address - Street 1:113 23RD AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144
Practice Address - Country:US
Practice Address - Phone:206-219-5980
Practice Address - Fax:206-812-6161
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00002170101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)