Healthcare Provider Details

I. General information

NPI: 1104395912
Provider Name (Legal Business Name): ESTEFANI MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ESTEFANI MEDINA

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12432 BELLFLOWER BLVD
DOWNEY CA
90242-2806
US

IV. Provider business mailing address

9680 SYCAMORE CANYON RD
MORENO VALLEY CA
92557-1813
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-6780
  • Fax: 818-241-6853
Mailing address:
  • Phone: 909-685-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number123566
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: