Provider Demographics
NPI:1821735101
Name:MEDINA, MICHAELA D (MSOT)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:D
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 ARNEYTOWN HORNERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CREAM RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08514-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 CRAIG RD STE 102
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8731
Practice Address - Country:US
Practice Address - Phone:732-761-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00972100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty