Provider Demographics
NPI:1881836310
Name:MEDINA, ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5912 RIVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1603
Mailing Address - Country:US
Mailing Address - Phone:347-275-9044
Mailing Address - Fax:347-602-5287
Practice Address - Street 1:5912 RIVERDALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1603
Practice Address - Country:US
Practice Address - Phone:347-275-9044
Practice Address - Fax:347-602-5287
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist