Provider Demographics
NPI:1548776339
Name:MEDINA, CARMEN E
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:E
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 1:7570 SW 82ND ST APT F110
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7395
Mailing Address - Country:US
Mailing Address - Phone:786-486-6869
Mailing Address - Fax:
Practice Address - Street 1:7570 SW 82ND ST APT F110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7395
Practice Address - Country:US
Practice Address - Phone:786-486-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-16
Last Update Date:2017-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician