Healthcare Provider Details

I. General information

NPI: 1972001899
Provider Name (Legal Business Name): MEDINA DAUTOVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S EL CAMINO REAL
SAN MATEO CA
94403-2380
US

IV. Provider business mailing address

2600 S EL CAMINO REAL
SAN MATEO CA
94403-2380
US

V. Phone/Fax

Practice location:
  • Phone: 650-578-8691
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberASW89224
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: