Provider Demographics
NPI:1487087037
Name:MEDINA, AMANDA (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79427 CALLE PALMETO
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-8554
Mailing Address - Country:US
Mailing Address - Phone:760-972-6966
Mailing Address - Fax:
Practice Address - Street 1:79427 CALLE PALMETO
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8554
Practice Address - Country:US
Practice Address - Phone:760-972-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical