Healthcare Provider Details

I. General information

NPI: 1952794307
Provider Name (Legal Business Name): MIMI MEDINA L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 BAINBRIDGE AVE APARTMENT 5E
BRONX NY
10458-2825
US

IV. Provider business mailing address

2929 BAINBRIDGE AVE APARTMENT 5E
BRONX NY
10458-2825
US

V. Phone/Fax

Practice location:
  • Phone: 718-365-9310
  • Fax:
Mailing address:
  • Phone: 718-365-9310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number072101
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: