Provider Demographics
NPI:1992271886
Name:MEDINA, ALICE (LCDC)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5134 GWENDA LEA ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78242-2416
Mailing Address - Country:US
Mailing Address - Phone:210-955-3796
Mailing Address - Fax:
Practice Address - Street 1:1852 LOCKHILL SELMA RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1500
Practice Address - Country:US
Practice Address - Phone:210-271-7411
Practice Address - Fax:210-271-9414
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14074101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)