Provider Demographics
NPI:1386808194
Name:MEDINA, MILDRED (PSYD)
Entity type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 18TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23500 KASSON RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376
Practice Address - Country:US
Practice Address - Phone:209-835-4141
Practice Address - Fax:209-830-3974
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21221103TC0700X
WAPY 60037300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical