MEDICARE: CHANILL MEDINA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		NY
2	101YM0800X	Mental Health Counselor		NJ

General Provider Information

NPI Number	:	1104414895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANILL MEDINA

Provider Business Mailing Address
First Line	:	971 US HIGHWAY 202 N STE 4143
Second Line	:
City	:	BRANCHBURG
State	:	NJ
Zip	:	08876-3757
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	971 US HIGHWAY 202 N STE 4143
Second Line	:
City	:	BRANCHBURG
State	:	NJ
Zip	:	08876-3757
Country	:	US
Telephone Number	:	845-600-0640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2021
Last Update Date	:	04/07/2026

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Directions to “ CHANILL MEDINA ” Practice Location

Language	Start Address	Practice Location

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