Provider Demographics
NPI:1497531735
Name:MEDINA, GENEVA EZEL
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:EZEL
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 1:152 ROYAL PALM DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-4071
Mailing Address - Country:US
Mailing Address - Phone:407-765-1381
Mailing Address - Fax:
Practice Address - Street 1:6100 LAKE ELLENOR DR STE 261
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4638
Practice Address - Country:US
Practice Address - Phone:407-968-7807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI65762355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant