Provider Demographics
NPI:1265917660
Name:MEDINA, RENE AGNE (LCSW)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:AGNE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:RENE
Other - Middle Name:AGNE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2421 26TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-7227
Mailing Address - Country:US
Mailing Address - Phone:610-413-5734
Mailing Address - Fax:
Practice Address - Street 1:2604 SCHOENERSVILLE RD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-3518
Practice Address - Country:US
Practice Address - Phone:610-691-8028
Practice Address - Fax:610-965-0608
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0193031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical