Provider Demographics
NPI:1205497013
Name:MEDINA, NATASHA MARIE (MED, LMHC)
Entity type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:MARIE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2155
Mailing Address - Country:US
Mailing Address - Phone:360-518-7688
Mailing Address - Fax:
Practice Address - Street 1:1104 MAIN ST STE M105
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2969
Practice Address - Country:US
Practice Address - Phone:360-518-7688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60969099101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health