Provider Demographics
NPI:1770222028
Name:SUSTACHE MEDINA, ANDREA JENNYS
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JENNYS
Last Name:SUSTACHE 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 1:3813 PERIWINKLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6046
Mailing Address - Country:US
Mailing Address - Phone:787-983-4456
Mailing Address - Fax:
Practice Address - Street 1:3813 PERIWINKLE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-6046
Practice Address - Country:US
Practice Address - Phone:787-983-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117625235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659249401Medicaid