Provider Demographics
NPI:1942077425
Name:MEDINA, CARLOS V
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MEDINA
Suffix:V
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 1:4504 N PAULINA ST APT 202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 W MONTROSE AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1562
Practice Address - Country:US
Practice Address - Phone:872-228-9632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health