Provider Demographics
NPI:1104414895
Name:MEDINA, CHANILL
Entity type:Individual
Prefix:
First Name:CHANILL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 ART LN APT 1
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1937
Mailing Address - Country:US
Mailing Address - Phone:551-815-2561
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
NJ101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health