MEDICARE: MR. ANTONIO C MEDINA MFT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	104550	CA
2	101YM0800X	Mental Health Counselor
3	106H00000X	Marriage & Family Therapist	49505	CA

General Provider Information

NPI Number	:	1205009768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTONIO C MEDINA MFT

Provider Business Mailing Address
First Line	:	5900 S LAKE FOREST DR
Second Line	:	SUITE 300
City	:	MCKINNEY
State	:	TX
Zip	:	75070-2193
Country	:	US
Telephone Number	:	469-708-7151
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 S LAKE FOREST DR
Second Line	:	SUITE 300
City	:	MCKINNEY
State	:	TX
Zip	:	75070-2193
Country	:	US
Telephone Number	:	469-708-7151
Fax Number	:

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

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	11/30/2016

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