Provider Demographics
NPI:1770064313
Name:MEDINA, KATHERINE IVONNE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:IVONNE
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 1:1231 E DYER RD STE 135
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5643
Mailing Address - Country:US
Mailing Address - Phone:714-944-7900
Mailing Address - Fax:
Practice Address - Street 1:2958 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5826
Practice Address - Country:US
Practice Address - Phone:626-743-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
1041C0700X
CA1245061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-3167866Medicaid