Provider Demographics
NPI:1245439348
Name:MEDVIN, LOI C (MA, PSYD)
Entity type:Individual
Prefix:DR
First Name:LOI
Middle Name:C
Last Name:MEDVIN
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 MCFARLANE AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4420
Mailing Address - Country:US
Mailing Address - Phone:707-695-7888
Mailing Address - Fax:
Practice Address - Street 1:825 COLLEGE AVE STE 4
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4108
Practice Address - Country:US
Practice Address - Phone:707-962-4196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA122742OtherMEDICARE ID