Provider Demographics
NPI:1831688472
Name:MEDINA, LISA M (RH0010460323)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RH0010460323
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W BEAMER ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2510
Mailing Address - Country:US
Mailing Address - Phone:530-405-2815
Mailing Address - Fax:530-204-5255
Practice Address - Street 1:215 W BEAMER ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2510
Practice Address - Country:US
Practice Address - Phone:530-405-2815
Practice Address - Fax:530-204-5255
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1298150318101YA0400X
390200000X
CAA063381123101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1298150318OtherCCAAP