Provider Demographics
NPI:1467285478
Name:CHANDRA MEDINA, MARRIAGE AND FAMILY THERAPY INC
Entity type:Organization
Organization Name:CHANDRA MEDINA, MARRIAGE AND FAMILY THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:714-326-3722
Mailing Address - Street 1:22792 CENTRE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6311
Mailing Address - Country:US
Mailing Address - Phone:714-326-3722
Mailing Address - Fax:
Practice Address - Street 1:22792 CENTRE DR STE 104
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6311
Practice Address - Country:US
Practice Address - Phone:714-326-3722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty