Healthcare Provider Details

I. General information

NPI: 1538736335
Provider Name (Legal Business Name): ALEXANDRA MEDINA LMHCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RICH ST
BUFFALO NY
14211-3020
US

IV. Provider business mailing address

741 DELAWARE AVE
BUFFALO NY
14209-2201
US

V. Phone/Fax

Practice location:
  • Phone: 716-895-7715
  • Fax:
Mailing address:
  • Phone: 716-218-1400
  • Fax: 716-332-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: