Provider Demographics
NPI:1841567930
Name:MEDINA, MARGIE G (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARGIE
Middle Name:G
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MARGARITA
Other - Middle Name:G
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:301 PERKINS DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:575-647-3773
Mailing Address - Fax:
Practice Address - Street 1:1681 HICKORY LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-6587
Practice Address - Country:US
Practice Address - Phone:575-647-3773
Practice Address - Fax:575-647-3777
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist