Provider Demographics
NPI:1558258863
Name:MEDINA, IVANA GISELLE
Entity type:Individual
Prefix:
First Name:IVANA
Middle Name:GISELLE
Last Name:MEDINA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12361 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4677
Mailing Address - Country:US
Mailing Address - Phone:714-253-4733
Mailing Address - Fax:
Practice Address - Street 1:12361 LEWIS ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4677
Practice Address - Country:US
Practice Address - Phone:714-253-4733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician