Provider Demographics
NPI:1932656675
Name:MEDINA, VICKIE (BSW, MSW)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BSW, MSW
Other - Prefix:MS
Other - First Name:VICKIE
Other - Middle Name:STEPHANIE
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSW,MSW
Mailing Address - Street 1:8912 VOLUNTEER LN
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3221
Mailing Address - Country:US
Mailing Address - Phone:916-344-0199
Mailing Address - Fax:
Practice Address - Street 1:212 I ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:707-536-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041S0200X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool