Provider Demographics
NPI:1184899379
Name:MEDINA, SUSAN
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91503-0706
Mailing Address - Country:US
Mailing Address - Phone:626-826-9910
Mailing Address - Fax:
Practice Address - Street 1:160 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-3211
Practice Address - Country:US
Practice Address - Phone:626-626-4200
Practice Address - Fax:626-626-4201
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN803OtherLA COUNTY DMH STAFF CODE