Provider Demographics
NPI:1801069497
Name:MEDINA, SHARON (MS ED)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 W CAPITOL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2070
Mailing Address - Country:US
Mailing Address - Phone:414-719-6633
Mailing Address - Fax:414-434-4253
Practice Address - Street 1:6815 W CAPITOL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2070
Practice Address - Country:US
Practice Address - Phone:414-719-6633
Practice Address - Fax:414-434-4253
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43733000Medicaid