Provider Demographics
NPI:1407156664
Name:MEDINA, DANIEL ENRIQUE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ENRIQUE
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1601 WESTPARK DR STE 3
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2432
Mailing Address - Country:US
Mailing Address - Phone:501-664-1717
Mailing Address - Fax:501-664-1720
Practice Address - Street 1:1601 WESTPARK DR STE 3
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2432
Practice Address - Country:US
Practice Address - Phone:501-664-1717
Practice Address - Fax:501-664-1720
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASL010118235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist