Provider Demographics
NPI:1396038063
Name:MEDINA, CRISTINA MOUSSAWEL
Entity Type:Individual
Prefix:MRS
First Name:CRISTINA
Middle Name:MOUSSAWEL
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRISTINA
Other - Middle Name:
Other - Last Name:MOUSSAWEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1542 SW 137TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2723
Mailing Address - Country:US
Mailing Address - Phone:305-431-7224
Mailing Address - Fax:
Practice Address - Street 1:7232 SW 39TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6624
Practice Address - Country:US
Practice Address - Phone:305-431-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-25466103K00000X, 103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019723000Medicaid