Healthcare Provider Details

I. General information

NPI: 1225859721
Provider Name (Legal Business Name): MEDALIA JUAREZ LMSW-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1938 N WOODLAWN ST STE 400
WICHITA KS
67208-1875
US

IV. Provider business mailing address

271 W 3RD ST N STE 600
WICHITA KS
67202-1223
US

V. Phone/Fax

Practice location:
  • Phone: 316-660-9600
  • Fax:
Mailing address:
  • Phone: 316-660-7600
  • Fax: 316-941-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13896-T
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: