Provider Demographics
NPI:1003676180
Name:MEDINA, AMBAR
Entity Type:Individual
Prefix:
First Name:AMBAR
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 1:642 KENWICK CIR APT 202
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-4259
Mailing Address - Country:US
Mailing Address - Phone:516-603-2066
Mailing Address - Fax:
Practice Address - Street 1:414 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5900
Practice Address - Country:US
Practice Address - Phone:407-637-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral