Provider Demographics
NPI:1093359614
Name:MEDINA, VANESSA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
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 1:2115 W PIKE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-0054
Mailing Address - Country:US
Mailing Address - Phone:956-377-8000
Mailing Address - Fax:
Practice Address - Street 1:2115 W PIKE BLVD
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-0054
Practice Address - Country:US
Practice Address - Phone:956-377-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116276OtherSPEECH LICENSE