Healthcare Provider Details

I. General information

NPI: 1871023911
Provider Name (Legal Business Name): MARIA DEL CARMEN PUENTE MEDINA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ENTERPRISE DR
YORKTOWN VA
23692-3190
US

IV. Provider business mailing address

100 ENTERPRISE DR
YORKTOWN VA
23692-3190
US

V. Phone/Fax

Practice location:
  • Phone: 757-736-3725
  • Fax: 757-431-7782
Mailing address:
  • Phone: 757-736-3725
  • Fax: 757-431-7782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW-2911
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-5274
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904018765
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6275C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: