Provider Demographics
NPI:1952825903
Name:MEDINA, EMMA (LCSW)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:RUIZ MERCADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:828 W VENTURA ST STE 240
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1882
Mailing Address - Country:US
Mailing Address - Phone:805-933-8660
Mailing Address - Fax:
Practice Address - Street 1:828 W VENTURA ST STE 240
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-1882
Practice Address - Country:US
Practice Address - Phone:805-524-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X, 390200000X
CA1098131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program