Provider Demographics
NPI:1104306430
Name:MEDINA, BIANCA DESIREE (LMFT)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:DESIREE
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 1:421 W BROADWAY APT 4156
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-9435
Mailing Address - Country:US
Mailing Address - Phone:213-465-0880
Mailing Address - Fax:
Practice Address - Street 1:510 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-265-0997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PCC12746101YP2500X
CAMFT131584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional