Provider Demographics
NPI:1396983656
Name:MEDINA, IVONNE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:IVONNE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8319 116TH ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-3433
Mailing Address - Country:US
Mailing Address - Phone:646-206-4420
Mailing Address - Fax:
Practice Address - Street 1:8319 116TH ST APT 2A
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3433
Practice Address - Country:US
Practice Address - Phone:646-206-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-25
Last Update Date:2009-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010720225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist