Provider Demographics
NPI:1003624750
Name:MEDINA GUTIERREZ, MERARY DEL CARMEN
Entity type:Individual
Prefix:
First Name:MERARY
Middle Name:DEL CARMEN
Last Name:MEDINA GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 3RD ST STE 106
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-2500
Mailing Address - Country:US
Mailing Address - Phone:916-757-3019
Mailing Address - Fax:
Practice Address - Street 1:1530 3RD ST STE 106
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-2500
Practice Address - Country:US
Practice Address - Phone:916-434-8927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1594070125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)