Basic Information
| Provider Information | |||||||||
| NPI: | 1114101755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | MAURA | ||||||||
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| Credential: | LPC, LMFT, LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 326 MORGAN ST STE D | ||||||||
| Address2: | |||||||||
| City: | HARKER HEIGHTS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765483078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 61677 | TX | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 10029 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 201013 | TX | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.