Healthcare Provider Details

I. General information

NPI: 1790648137
Provider Name (Legal Business Name): MICAELA TAMARA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7323 SIDEWINDER DR NE
ALBUQUERQUE NM
87113-1300
US

IV. Provider business mailing address

7323 SIDEWINDER DR NE
ALBUQUERQUE NM
87113-1300
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-7633
  • Fax:
Mailing address:
  • Phone: 505-350-7633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCBT-2024-0831
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: