Provider Demographics
NPI:1164976288
Name:MEDINA, ABIGAIL THERESA
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:THERESA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6022 S LINDBERGH BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7019
Mailing Address - Country:US
Mailing Address - Phone:314-845-7751
Mailing Address - Fax:
Practice Address - Street 1:6022 S LINDBERGH BLVD # 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7019
Practice Address - Country:US
Practice Address - Phone:314-845-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021291235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist