Provider Demographics
NPI:1588413959
Name:MEDINA, ALEXANDER (CAS BS)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:CAS BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 ASTER ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3179
Mailing Address - Country:US
Mailing Address - Phone:719-553-7172
Mailing Address - Fax:
Practice Address - Street 1:509 E 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2940
Practice Address - Country:US
Practice Address - Phone:719-546-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0021158101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)