Provider Demographics
NPI:1033657838
Name:MEDINA CASTILLO, PAOLA ELIZABETH (BCABA)
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:ELIZABETH
Last Name:MEDINA CASTILLO
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2885 SE 1ST DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7261
Mailing Address - Country:US
Mailing Address - Phone:786-678-8148
Mailing Address - Fax:
Practice Address - Street 1:2885 SE 1ST DR UNIT 1
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7261
Practice Address - Country:US
Practice Address - Phone:786-678-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL0-19-10237106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019814800Medicaid