Provider Demographics
NPI:1164000139
Name:MEDINA, CHRISTINE GAYLE (SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GAYLE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 PINECONE CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2725
Mailing Address - Country:US
Mailing Address - Phone:502-533-2424
Mailing Address - Fax:
Practice Address - Street 1:200 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1277
Practice Address - Country:US
Practice Address - Phone:502-245-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist