Provider Demographics
NPI:1699805812
Name:MEDLIN, GARY LEE (MFT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:MEDLIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2261 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-3721
Mailing Address - Country:US
Mailing Address - Phone:707-253-4166
Mailing Address - Fax:707-299-4072
Practice Address - Street 1:5121 STOCKDALE HWY
Practice Address - Street 2:STE. 275
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-2656
Practice Address - Country:US
Practice Address - Phone:661-868-5000
Practice Address - Fax:661-836-8834
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9467101YP2500X
CAMFC 47118106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional