Shannon Monique Medina
Individual provider Active NPI Social Worker · Penasco, NM
NPI 1366092645 · NPPES record last updated Sep 18, 2019
Key facts
- NPI
- 1366092645
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Social Worker 104100000X
- License
- X-11248 (NM)
- Practice address
- 13 Old School Rd
Penasco, NM 87553 - Phone
- (575) 587-2502
- NPI assigned
- Sep 18, 2019
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| X-11248 | NM | MD | Social Worker |
| 376369 | NM | MD | School Social Worker |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| School Social Worker | 1041S0200X | 376369 | NM | |
| Social Worker | 104100000X | X-11248 | NM | Yes |
Addresses
Primary practice location
13 Old School Rd
Penasco, NM 87553
Mailing address
PO Box 520
Penasco, NM 87553-0520
Phone (575) 587-2502
Other providers in Penasco, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 18, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.