Provider Demographics
NPI:1154709483
Name:MEDINA, GLORIA ESTHER
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:ESTHER
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5230
Mailing Address - Country:US
Mailing Address - Phone:909-421-4616
Mailing Address - Fax:909-421-9466
Practice Address - Street 1:820 E. GILBERT ST.
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415
Practice Address - Country:US
Practice Address - Phone:909-386-8510
Practice Address - Fax:909-387-7757
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16872101YA0400X
CA196098-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)