Provider Demographics
NPI:1871052290
Name:MEDINA, DIANA MARIE (LCAS, LCSWA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LCAS, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 NEW RIVER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6006
Mailing Address - Country:US
Mailing Address - Phone:910-545-9944
Mailing Address - Fax:
Practice Address - Street 1:2000 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-633-8204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24929101YA0400X
NCLCAS-4929101YA0400X
NCP015340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)