Provider Demographics
NPI:1275141020
Name:MEDINA, CLEO MARIELLE
Entity Type:Individual
Prefix:
First Name:CLEO
Middle Name:MARIELLE
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 1:1616 N CENTRAL AVE APT 2140
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1662
Mailing Address - Country:US
Mailing Address - Phone:469-888-1149
Mailing Address - Fax:
Practice Address - Street 1:2150 S 87TH AVE
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-7000
Practice Address - Country:US
Practice Address - Phone:623-474-7000
Practice Address - Fax:623-936-9253
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist