Provider Demographics
NPI:1194238048
Name:MEDINA, LOURDES DE LA CARIDAD
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:DE LA CARIDAD
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 SW 5TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1543
Mailing Address - Country:US
Mailing Address - Phone:786-567-2800
Mailing Address - Fax:
Practice Address - Street 1:10752 SW 5TH ST APT 1
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1543
Practice Address - Country:US
Practice Address - Phone:786-567-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician