Healthcare Provider Details

I. General information

NPI: 1104414895
Provider Name (Legal Business Name): CHANILL MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CEDAR LN STE 102
TEANECK NJ
07666-4457
US

IV. Provider business mailing address

121 CEDAR LN STE 102
TEANECK NJ
07666-4457
US

V. Phone/Fax

Practice location:
  • Phone: 201-357-9885
  • Fax:
Mailing address:
  • Phone: 201-357-9885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37FI00255300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002774
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: