Provider Demographics
NPI:1528562402
Name:MEDINA, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
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 1:2120 EAST LASALLE STREET
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909
Mailing Address - Country:US
Mailing Address - Phone:303-521-3811
Mailing Address - Fax:
Practice Address - Street 1:2120 EAST LASALLE STREET
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-466-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103K00000X
CO11512106E00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician