Basic Information
| Provider Information | |||||||||
| NPI: | 1699827592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | ROSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34054 | ||||||||
| Address2: | |||||||||
| City: | GRANADA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913944054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185153237 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10605 BALBOA BLVD | ||||||||
| Address2: | |||||||||
| City: | GRANADA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913446342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188322400 | ||||||||
| FaxNumber: | 8188326197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW12922 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.