Basic Information
Provider Information
NPI: 1457607764
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MEDINA
FirstName: MARLYN
MiddleName: E
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 12730 MUSCATINE ST
Address2:  
City: ARLETA
State: CA
PostalCode: 913314243
CountryCode: US
TelephoneNumber: 8188158680
FaxNumber:  
Practice Location
Address1: 15305 RAYEN ST
Address2:  
City: NORTH HILLS
State: CA
PostalCode: 913435117
CountryCode: US
TelephoneNumber: 8188923423
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/24/2012
LastUpdateDate: 09/21/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/21/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  N Other Service ProvidersCase Manager/Care Coordinator 
390200000X  N193400000X MULTIPLE SINGLE SPECIALTY GROUPStudent, Health CareStudent in an Organized Health Care Education/Training Program 
390200000X CAN Student, Health CareStudent in an Organized Health Care Education/Training Program 
101YM0800X CAY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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