Basic Information
| Provider Information | |||||||||
| NPI: | 1699805812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDLIN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2261 ELM ST | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945593721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072534166 | ||||||||
| FaxNumber: | 7072994072 | ||||||||
| Practice Location | |||||||||
| Address1: | 5121 STOCKDALE HWY | ||||||||
| Address2: | STE. 275 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933092656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618685000 | ||||||||
| FaxNumber: | 6618368834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 9467 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | MFC 47118 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.