Basic Information
| Provider Information | |||||||||
| NPI: | 1821253642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CASAC-T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15648 77TH ST | ||||||||
| Address2: | |||||||||
| City: | HOWARD BEACH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114142569 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 80-20 KEW GARDENS | ||||||||
| Address2: | SUITE 704 | ||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185201513 | ||||||||
| FaxNumber: | 7185206460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 20290 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.