Provider Demographics
NPI:1225765688
Name:MEDINA, AIESHA-AGYEMARAI (PHD)
Entity Type:Individual
Prefix:
First Name:AIESHA-AGYEMARAI
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5000-452
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683
Mailing Address - Country:US
Mailing Address - Phone:939-942-1463
Mailing Address - Fax:
Practice Address - Street 1:CARR.324 KM. 2.1 BO. ENSENADA EL BATEY
Practice Address - Street 2:
Practice Address - City:GUANICA
Practice Address - State:PR
Practice Address - Zip Code:00653
Practice Address - Country:US
Practice Address - Phone:787-821-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical