Provider Demographics
NPI:1124878368
Name:MEDINA NGUYEN, LISA (LMSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MEDINA NGUYEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9909 KEATHLY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-2449
Mailing Address - Country:US
Mailing Address - Phone:817-718-1080
Mailing Address - Fax:
Practice Address - Street 1:2201 SE LOOP 820
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-5863
Practice Address - Country:US
Practice Address - Phone:817-718-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104758104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker