Basic Information
| Provider Information | |||||||||
| NPI: | 1265917660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | AGNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPEZ | ||||||||
| OtherFirstName: | RENE | ||||||||
| OtherMiddleName: | AGNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2421 26TH ST SW | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181037227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104135734 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2604 SCHOENERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180173518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106918028 | ||||||||
| FaxNumber: | 6109650608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW019303 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.