Provider Demographics
NPI:1033609904
Name:MEDINA, MILAGROS (RBT-17-39927)
Entity Type:Individual
Prefix:
First Name:MILAGROS
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RBT-17-39927
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5357 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1280
Mailing Address - Country:US
Mailing Address - Phone:708-745-1160
Mailing Address - Fax:
Practice Address - Street 1:5357 W 87TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1280
Practice Address - Country:US
Practice Address - Phone:708-745-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-39927106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician