Provider Demographics
NPI:1487082160
Name:MEDINA, VICTOR (MSW)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. MONTE ELENA, MAGNOLIA ST. # 144
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00646
Mailing Address - Country:UM
Mailing Address - Phone:787-310-7031
Mailing Address - Fax:
Practice Address - Street 1:URB. MONTE ELENA, MAGNOLIA ST. # 144
Practice Address - Street 2:
Practice Address - City:DORADO
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00646
Practice Address - Country:UM
Practice Address - Phone:787-310-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR118251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical