Provider Demographics
NPI:1043071160
Name:MEDINA SIERRA, LUIS CARLOS
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:CARLOS
Last Name:MEDINA SIERRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 10TH AVE N APT 203
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6744
Mailing Address - Country:US
Mailing Address - Phone:561-703-7927
Mailing Address - Fax:
Practice Address - Street 1:2785 10TH AVE N APT 203
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-6744
Practice Address - Country:US
Practice Address - Phone:561-703-7927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT23315039106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician