MEDICARE: MELISSA MEDINA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	32665	TX

General Provider Information

NPI Number	:	1134343536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MEDINA LCSW

Provider Business Mailing Address
First Line	:	1802 GREENGRASS CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1120
Country	:	US
Telephone Number	:	713-303-5144
Fax Number	:	713-723-7303

Provider Business Practice Location Address
First Line	:	5505 W OREM DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77085-1276
Country	:	US
Telephone Number	:	832-828-3420
Fax Number	:	713-723-7303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	09/07/2010

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