Provider Demographics
NPI:1851769806
Name:MEDINA, REYNALDO
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 EASTGATE DR
Mailing Address - Street 2:APT 5403
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6430
Mailing Address - Country:US
Mailing Address - Phone:920-904-0369
Mailing Address - Fax:
Practice Address - Street 1:4150 EASTGATE DR
Practice Address - Street 2:APT 5403
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-6430
Practice Address - Country:US
Practice Address - Phone:920-904-0369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst