Healthcare Provider Details

I. General information

NPI: 1891500708
Provider Name (Legal Business Name): MICHELLE MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2025
Last Update Date: 02/08/2025
Certification Date: 02/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12103 S 29TH ST
BELLEVUE NE
68123-1404
US

IV. Provider business mailing address

14210 ARBOR ST
OMAHA NE
68144-2385
US

V. Phone/Fax

Practice location:
  • Phone: 909-246-8896
  • Fax:
Mailing address:
  • Phone: 531-999-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number3747P1801X
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: