Provider Demographics
NPI:1922643022
Name:MEDINA, CECILIA ISABEL
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:ISABEL
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CECILIA
Other - Middle Name:ISABEL
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6824
Mailing Address - Country:US
Mailing Address - Phone:310-253-9494
Mailing Address - Fax:
Practice Address - Street 1:9808 VENICE BLVD STE 700
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6824
Practice Address - Country:US
Practice Address - Phone:310-253-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CARBT-21-165481106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician