Provider Demographics
NPI:1023318813
Name:MEDINA, LISA C (LCDC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:CARRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2010 ROCKLAND DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-3066
Mailing Address - Country:US
Mailing Address - Phone:512-809-6390
Mailing Address - Fax:512-454-5039
Practice Address - Street 1:5808 BALCONES DR
Practice Address - Street 2:201
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4255
Practice Address - Country:US
Practice Address - Phone:512-804-3650
Practice Address - Fax:512-476-0217
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11182101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)