Provider Demographics
NPI:1386210672
Name:MEDINA, KELLY (MS, CF-SLP, TSSLD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MS, CF-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 HILTON HEAD PL APT 1174
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-4431
Mailing Address - Country:US
Mailing Address - Phone:516-710-9190
Mailing Address - Fax:
Practice Address - Street 1:690 OTAY LAKES RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-8904
Practice Address - Country:US
Practice Address - Phone:619-475-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist