Basic Information
| Provider Information | |||||||||
| NPI: | 1629413539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | ALBA | ||||||||
| MiddleName: | ALEJANDRA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT 113496 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095965921 | ||||||||
| FaxNumber: | 9095963954 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095965921 | ||||||||
| FaxNumber: | 9095963954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | INTERN 71014 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 113496 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.