Basic Information
| Provider Information | |||||||||
| NPI: | 1205088069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLEMENTS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 920 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882405529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753933168 | ||||||||
| FaxNumber: | 5753974659 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882405529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753933168 | ||||||||
| FaxNumber: | 5753974659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 10/10/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0089661 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.