Healthcare Provider Details

I. General information

NPI: 1902010572
Provider Name (Legal Business Name): EDWARD MEDINA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 STEUBEN AVE
BRONX NY
10467-2806
US

IV. Provider business mailing address

105 LINDA PL
CORTLANDT MANOR NY
10567-1632
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4955
  • Fax:
Mailing address:
  • Phone: 914-734-2163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR037867
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: