Provider Demographics
NPI:1801548250
Name:MEDINA, NICOLE G
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
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 1:1751 COLORADO BLVD # 180
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1348
Mailing Address - Country:US
Mailing Address - Phone:213-379-5371
Mailing Address - Fax:
Practice Address - Street 1:250 EL CAMINO REAL STE 213
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3656
Practice Address - Country:US
Practice Address - Phone:714-805-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA135401106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program