Provider Demographics
NPI:1730669888
Name:MEDINA, WESLEY MARTIN
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:MARTIN
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 NORMAL AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-6054
Mailing Address - Country:US
Mailing Address - Phone:323-839-5285
Mailing Address - Fax:
Practice Address - Street 1:130 YELLOWSTONE DR STE 100
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-5884
Practice Address - Country:US
Practice Address - Phone:530-879-5991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT138428106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty