Provider Demographics
NPI:1811549835
Name:MEDINA, ANDREW G (MA, LBA, BCBA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:G
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MA, LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 S ELLSWORTH RD STE 115
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2165
Mailing Address - Country:US
Mailing Address - Phone:602-579-7961
Mailing Address - Fax:
Practice Address - Street 1:2919 S ELLSWORTH RD STE 115
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2165
Practice Address - Country:US
Practice Address - Phone:602-579-7961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-23-66131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst