Provider Demographics
NPI:1770757445
Name:MEDINA, MARISA DENISE (LCSW127143)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:DENISE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW127143
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12813 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90601-4118
Mailing Address - Country:US
Mailing Address - Phone:562-693-0400
Mailing Address - Fax:
Practice Address - Street 1:17343 ANASTASIA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-4933
Practice Address - Country:US
Practice Address - Phone:626-201-6674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CALCSW1271431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA02870709Medicare PIN