Provider Demographics
NPI:1598891038
Name:MEDINA, LORRAINE TERESA (SLP)
Entity Type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:TERESA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BURLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-3005
Mailing Address - Country:US
Mailing Address - Phone:631-868-0969
Mailing Address - Fax:
Practice Address - Street 1:135 BURLEIGH DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-3005
Practice Address - Country:US
Practice Address - Phone:631-868-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010175-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist