=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588206411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDINATHERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2019
-----------------------------------------------------
Last Update Date | 10/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5900 S LAKE FOREST DR STE 300
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-708-7151
-----------------------------------------------------
Fax | 858-836-5708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5900 S LAKE FOREST DR STE 300
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-708-7151
-----------------------------------------------------
Fax | 858-836-5708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LMFT/OWNER
-----------------------------------------------------
Name | ANTONIO MEDINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-708-7151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------