MEDICARE: DR. EDWARDO J MEDINA JR. PHD THD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number
1	101YM0800X	Mental Health Counselor	SW081981
2	1041C0700X	Clinical Social Worker	SW081981
3	106H00000X	Marriage & Family Therapist	SW081981

General Provider Information

NPI Number	:	1437370137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARDO J MEDINA JR. PHD THD

Provider Business Mailing Address
First Line	:	PO BOX 0891
Second Line	:	KABBELAH SW NY NJ GROUP
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-0891
Country	:	US
Telephone Number	:	718-720-0292
Fax Number	:	718-761-5562

Provider Business Practice Location Address
First Line	:	800 MANOR RD #2V
Second Line	:	PROFESSIONAL SUITES #2V
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-7016
Country	:	US
Telephone Number	:	646-266-4010
Fax Number	:	718-761-5562

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	09/11/2025

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