Healthcare Provider Details

I. General information

NPI: 1891557591
Provider Name (Legal Business Name): WENDY MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST
GARDENA CA
90248-4320
US

IV. Provider business mailing address

1225 W 190TH ST
GARDENA CA
90248-4320
US

V. Phone/Fax

Practice location:
  • Phone: 310-515-8113
  • Fax:
Mailing address:
  • Phone: 310-515-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number144504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: