Provider Demographics
NPI:1972025906
Name:MEDINA, MARK STANLEY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STANLEY
Last Name:MEDINA
Suffix:
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 1:12 CAROL ST
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-2110
Mailing Address - Country:US
Mailing Address - Phone:413-531-8907
Mailing Address - Fax:
Practice Address - Street 1:179 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1057
Practice Address - Country:US
Practice Address - Phone:413-588-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health