Healthcare Provider Details

I. General information

NPI: 1861317455
Provider Name (Legal Business Name): MELISSA ASHLEY MEDINA-LONGBINE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 CARDINAL RD
MANSFIELD TX
76063-6300
US

IV. Provider business mailing address

812 CARDINAL RD
MANSFIELD TX
76063-6300
US

V. Phone/Fax

Practice location:
  • Phone: 972-922-5448
  • Fax:
Mailing address:
  • Phone: 972-922-5448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number56646
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: