Provider Demographics
NPI:1104267657
Name:MEDINA, MEGAN (MASTERS)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1337
Mailing Address - Country:US
Mailing Address - Phone:845-535-3167
Mailing Address - Fax:
Practice Address - Street 1:1 ODELL PLZ
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1402
Practice Address - Country:US
Practice Address - Phone:914-965-1152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1203267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst