Provider Demographics
NPI:1508169673
Name:MEDINA, CARMEN ENID
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:ENID
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 1:22 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-2317
Mailing Address - Country:US
Mailing Address - Phone:914-693-0149
Mailing Address - Fax:
Practice Address - Street 1:2340 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-6001
Practice Address - Country:US
Practice Address - Phone:718-365-7238
Practice Address - Fax:718-584-3057
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006423-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist