Provider Demographics
NPI:1518709542
Name:MEDINA, CAROLYN MICHELLE
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MICHELLE
Last Name:MEDINA
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 1:16400 VENTURA BLVD STE 327
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2190
Mailing Address - Country:US
Mailing Address - Phone:747-777-9454
Mailing Address - Fax:
Practice Address - Street 1:16400 VENTURA BLVD STE 327
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2190
Practice Address - Country:US
Practice Address - Phone:818-564-7281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst