=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528847480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE MEDINA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20008 CHAMPION FOREST DR
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-8694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 998-689-2281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25120 PANTHER BEND CT APT 332
-----------------------------------------------------
City | THE WOODLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77380-4237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-251-3387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------