Provider Demographics
NPI:1922769371
Name:MEDINA, RAQUEL (MT-BC)
Entity Type:Individual
Prefix:MISS
First Name:RAQUEL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 N 16TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7159
Mailing Address - Country:US
Mailing Address - Phone:602-840-6410
Mailing Address - Fax:
Practice Address - Street 1:3221 N 16TH ST STE 201
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7159
Practice Address - Country:US
Practice Address - Phone:602-840-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16957225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist