Provider Demographics
NPI:1205088069
Name:MEDINA, STEPHANIE E (LMHC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:E
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:920 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-5529
Mailing Address - Country:US
Mailing Address - Phone:575-393-3168
Mailing Address - Fax:575-397-4659
Practice Address - Street 1:920 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-5529
Practice Address - Country:US
Practice Address - Phone:575-393-3168
Practice Address - Fax:575-397-4659
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0089661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health