Provider Demographics
NPI:1083810394
Name:MEDINA, MARLO ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARLO
Middle Name:ANN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11107 ICICLE BENCH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5423
Mailing Address - Country:US
Mailing Address - Phone:210-617-8332
Mailing Address - Fax:
Practice Address - Street 1:11107 ICICLE BENCH
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-5423
Practice Address - Country:US
Practice Address - Phone:210-617-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist