Provider Demographics
NPI:1447905997
Name:MEDINA, PAULIQUE FANOURIA (LMSW)
Entity type:Individual
Prefix:
First Name:PAULIQUE
Middle Name:FANOURIA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:PAULIQUE
Other - Middle Name:
Other - Last Name:CARDONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2258 47TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1310
Mailing Address - Country:US
Mailing Address - Phone:646-884-3269
Mailing Address - Fax:
Practice Address - Street 1:2258 47TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1310
Practice Address - Country:US
Practice Address - Phone:646-884-3269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist