=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699805812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY LEE MEDLIN MFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 07/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5121 STOCKDALE HWY STE. 275
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93309-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-868-5000
-----------------------------------------------------
Fax | 661-836-8834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2261 ELM ST
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94559-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-253-4166
-----------------------------------------------------
Fax | 707-299-4072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 9467
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 47118
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------