Provider Demographics
NPI:1184016388
Name:MEDLIN, MICHAEL T (LBA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:MEDLIN
Suffix:
Gender:M
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 FRUITRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-6006
Mailing Address - Country:US
Mailing Address - Phone:863-409-5843
Mailing Address - Fax:
Practice Address - Street 1:1933 FRUITRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-6006
Practice Address - Country:US
Practice Address - Phone:863-409-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALABA10000153103K00000X
WABA61229386103K00000X
A-3344727171400000X
RBT-23-284540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty