Provider Demographics
NPI:1801307830
Name:MEDINA, DEANA
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:
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 1:9808 VENICE BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6818
Mailing Address - Country:US
Mailing Address - Phone:310-237-0461
Mailing Address - Fax:310-945-3356
Practice Address - Street 1:720 SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2703
Practice Address - Country:US
Practice Address - Phone:805-284-1536
Practice Address - Fax:310-945-3356
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA144292106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program