Provider Demographics
NPI:1457906638
Name:MEDINA, KATHLEEN (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:369 MILL DAM RD
Mailing Address - Street 2:
Mailing Address - City:CHESWICK
Mailing Address - State:PA
Mailing Address - Zip Code:15024-4103
Mailing Address - Country:US
Mailing Address - Phone:412-848-6490
Mailing Address - Fax:
Practice Address - Street 1:369 MILL DAM RD
Practice Address - Street 2:
Practice Address - City:CHESWICK
Practice Address - State:PA
Practice Address - Zip Code:15024-4103
Practice Address - Country:US
Practice Address - Phone:412-848-6490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-19-36106103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty