Provider Demographics
NPI:1780064154
Name:MEDINA, JUAN MIGUEL (LCSW)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:MIGUEL
Last Name:MEDINA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-3310
Mailing Address - Country:US
Mailing Address - Phone:661-747-2697
Mailing Address - Fax:
Practice Address - Street 1:4706 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-3310
Practice Address - Country:US
Practice Address - Phone:661-747-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX634161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX63416OtherTEXAS BEHAVIORAL HEALTH EXECUTIVE COUNCIL