Provider Demographics
NPI:1558124495
Name:MEDINA MARTINEZ, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MEDINA MARTINEZ
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 1:2231 SW 43RD TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-6633
Mailing Address - Country:US
Mailing Address - Phone:954-270-4077
Mailing Address - Fax:
Practice Address - Street 1:23123 SR-7
Practice Address - Street 2:UNIT 205
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428
Practice Address - Country:US
Practice Address - Phone:561-461-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician