Healthcare Provider Details

I. General information

NPI: 1710476213
Provider Name (Legal Business Name): ANDREW D MEDINA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0990
  • Fax: 602-933-4251
Mailing address:
  • Phone: 602-933-1813
  • Fax: 602-992-6209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17122
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: