Healthcare Provider Details

I. General information

NPI: 1699805812
Provider Name (Legal Business Name): GARY LEE MEDLIN MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 STOCKDALE HWY STE. 275
BAKERSFIELD CA
93309-2656
US

IV. Provider business mailing address

2261 ELM ST
NAPA CA
94559-3721
US

V. Phone/Fax

Practice location:
  • Phone: 661-868-5000
  • Fax: 661-836-8834
Mailing address:
  • Phone: 707-253-4166
  • Fax: 707-299-4072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9467
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 47118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: