Healthcare Provider Details

I. General information

NPI: 1265958565
Provider Name (Legal Business Name): INGRID VERONICA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 SILVER AVE # 2
SAN FRANCISCO CA
94134-1229
US

IV. Provider business mailing address

338 ALEMANY BLVD APT 3
SAN FRANCISCO CA
94110-6156
US

V. Phone/Fax

Practice location:
  • Phone: 415-657-1700
  • Fax:
Mailing address:
  • Phone: 925-621-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number84690
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number109606
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW109606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: