Healthcare Provider Details

I. General information

NPI: 1770365488
Provider Name (Legal Business Name): CATHERINE MEDINA CCHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 GUSDORF RD
TAOS NM
87571-6282
US

IV. Provider business mailing address

538 N PASEO DE ONATE
ESPANOLA NM
87532-2618
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-3601
  • Fax:
Mailing address:
  • Phone: 505-753-7218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberG-011
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: