Basic Information
| Provider Information | |||||||||
| NPI: | 1073126165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | BEATRIZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S TUSTIN ST BLDG D | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928662550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142893936 | ||||||||
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| Address1: | 401 S TUSTIN ST BLDG D | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928662550 | ||||||||
| CountryCode: | US | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 119570 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.