Provider Demographics
NPI:1578767505
Name:MEDINA RUIZ, NIDIA E (PHD)
Entity Type:Individual
Prefix:MRS
First Name:NIDIA
Middle Name:E
Last Name:MEDINA RUIZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 ORLANDO CENTRAL PKWY STE 480
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-5785
Mailing Address - Country:US
Mailing Address - Phone:321-337-8225
Mailing Address - Fax:
Practice Address - Street 1:1707 ORLANDO CENTRAL PKWY STE 480
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5785
Practice Address - Country:US
Practice Address - Phone:321-337-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15715101YM0800X, 101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator