Provider Demographics
NPI:1558971960
Name:MESA MEDINA, ISIS NIURIS
Entity Type:Individual
Prefix:
First Name:ISIS
Middle Name:NIURIS
Last Name:MESA 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 1:110 SEGOVIA CT
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1150
Mailing Address - Country:US
Mailing Address - Phone:561-618-7584
Mailing Address - Fax:
Practice Address - Street 1:110 SEGOVIA CT
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-1150
Practice Address - Country:US
Practice Address - Phone:561-618-7584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-124272106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician