Provider Demographics
NPI:1255646626
Name:MEDINA, HONOR JOHNSON (LMFT)
Entity type:Individual
Prefix:
First Name:HONOR
Middle Name:JOHNSON
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5110
Mailing Address - Country:US
Mailing Address - Phone:575-885-4836
Mailing Address - Fax:575-628-0676
Practice Address - Street 1:914 N CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5110
Practice Address - Country:US
Practice Address - Phone:575-885-4836
Practice Address - Fax:575-628-0676
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0097731106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist