Healthcare Provider Details

I. General information

NPI: 1467826222
Provider Name (Legal Business Name): MELISSA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PINE ST SUITE 1250 (PRIVATE OFFICE 3)
SAN FRANCISCO CA
94111-5102
US

IV. Provider business mailing address

3340 W 83RD ST
INGLEWOOD CA
90305-1741
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax: 888-815-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW86730
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34011168A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW67931
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2405368
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12946-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: