Provider Demographics
NPI:1063270387
Name:MEDINA, GABRIEL ANDRES
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ANDRES
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 1:7658 W 34TH LN UNIT 203
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5028
Mailing Address - Country:US
Mailing Address - Phone:786-403-7918
Mailing Address - Fax:
Practice Address - Street 1:7658 W 34TH LN UNIT 203
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-5028
Practice Address - Country:US
Practice Address - Phone:786-403-7918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1067183106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician