Healthcare Provider Details

I. General information

NPI: 1730669888
Provider Name (Legal Business Name): MR. WESLEY MARTIN MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 YELLOWSTONE DR STE 100
CHICO CA
95973-5884
US

IV. Provider business mailing address

1004 NORMAL AVE UNIT B
CHICO CA
95928-6054
US

V. Phone/Fax

Practice location:
  • Phone: 530-879-5991
  • Fax:
Mailing address:
  • Phone: 323-839-5285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT138428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: