Provider Demographics
NPI:1306664412
Name:MEDINA RIVERA, DANNY
Entity type:Individual
Prefix:
First Name:DANNY
Middle Name:
Last Name:MEDINA RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5657 AMESBURY DR APT 1301
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3070
Mailing Address - Country:US
Mailing Address - Phone:469-324-9842
Mailing Address - Fax:
Practice Address - Street 1:5657 AMESBURY DR APT 1301
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-3070
Practice Address - Country:US
Practice Address - Phone:469-324-9842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78632101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional