Provider Demographics
NPI:1285016121
Name:MINA, MARINA TAWADROUS (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:TAWADROUS
Last Name:MINA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 S ORLANDO AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5654
Mailing Address - Country:US
Mailing Address - Phone:407-790-5601
Mailing Address - Fax:
Practice Address - Street 1:800 WESTWOOD SQ STE D
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8849
Practice Address - Country:US
Practice Address - Phone:407-790-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14146770235Z00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist