Provider Demographics
NPI:1255821708
Name:MEDINA, MICHELLE (BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 W 56TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6501
Mailing Address - Country:US
Mailing Address - Phone:786-247-7153
Mailing Address - Fax:
Practice Address - Street 1:657 SOUTH DR STE 403
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-5926
Practice Address - Country:US
Practice Address - Phone:786-860-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021768000Medicaid