Provider Demographics
NPI:1861774978
Name:MEDINA, LOUISIANA
Entity type:Individual
Prefix:
First Name:LOUISIANA
Middle Name:
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 1:3751 STOCKER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5101
Mailing Address - Country:US
Mailing Address - Phone:323-298-3680
Mailing Address - Fax:
Practice Address - Street 1:510 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-760-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA76169104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker