Healthcare Provider Details

I. General information

NPI: 1679284004
Provider Name (Legal Business Name): LETICIA MEDINA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N. TWIN OAKS VALLEY RD #432
SAN MARCOS CA
92069
US

IV. Provider business mailing address

420 N. TWIN OAKS VALLEY RD #432
SAN MARCOS CA
92069
US

V. Phone/Fax

Practice location:
  • Phone: 760-539-8049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: