Healthcare Provider Details

I. General information

NPI: 1003624750
Provider Name (Legal Business Name): MERARY DEL CARMEN MEDINA GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2024
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 3RD ST STE 106
LINCOLN CA
95648-2500
US

IV. Provider business mailing address

1530 3RD ST STE 106
LINCOLN CA
95648-2500
US

V. Phone/Fax

Practice location:
  • Phone: 916-434-8927
  • Fax:
Mailing address:
  • Phone: 916-757-3019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1594070125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: