| Doctor Name: | MARY RUTH MEDINA |
| NPI Number: | 1245450717 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | BS |
| License Number: | |
| Business Practice Address: | 108 S Witte St Poteau, OK - 749534208 |
| Business Phone Number: | 9186473546 |
| Business Fax Number: | 9186474003 |
| Mailing Address: | 30898 B W 31 Hwy, KINTA |
| State: | OK |
| Postal Code: | 74552 |
| Phone Number: | 9187683393 |
| Fax Number: | |
| NPI Enumeration Date: | 04/26/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |