Provider Demographics
NPI:1760116925
Name:MEDINA, ALYSSA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3100
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-3100
Mailing Address - Country:US
Mailing Address - Phone:575-613-3144
Mailing Address - Fax:
Practice Address - Street 1:7278 HIGHWAY 518
Practice Address - Street 2:
Practice Address - City:RANCHOS DE TAOS
Practice Address - State:NM
Practice Address - Zip Code:87557-8830
Practice Address - Country:US
Practice Address - Phone:575-613-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NMCTB-2025-0155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health