Provider Demographics
NPI:1952637803
Name:MEDINA, LPCC, BRENDA BERENICE (LPCC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:BERENICE
Last Name:MEDINA, LPCC
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 BECKNER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3691
Mailing Address - Country:US
Mailing Address - Phone:505-989-4500
Mailing Address - Fax:
Practice Address - Street 1:4730 BECKNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3691
Practice Address - Country:US
Practice Address - Phone:505-989-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0126261101YM0800X
NMCCMH0159131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health