Provider Demographics
NPI:1265958565
Name:MEDINA, INGRID VERONICA
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:VERONICA
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 1:338 ALEMANY BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-6156
Mailing Address - Country:US
Mailing Address - Phone:925-621-9702
Mailing Address - Fax:
Practice Address - Street 1:1525 SILVER AVE # 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-1229
Practice Address - Country:US
Practice Address - Phone:415-657-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84690101YM0800X
CA1096061041C0700X
CALCSW1096061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90903175D26028Medicaid