Provider Demographics
NPI:1649088667
Name:MEDINA, BRANDON DANIEL
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:DANIEL
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 KINSLEY WAY
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-0285
Mailing Address - Country:US
Mailing Address - Phone:210-952-0570
Mailing Address - Fax:
Practice Address - Street 1:133 WINDY MEADOWS DR
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-1539
Practice Address - Country:US
Practice Address - Phone:210-405-2427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician