Provider Demographics
NPI:1215570494
Name:MEDUNOVA, ELENA
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:MEDUNOVA
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 1:542 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1016
Mailing Address - Country:US
Mailing Address - Phone:978-528-5210
Mailing Address - Fax:
Practice Address - Street 1:542 AMHERST ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1016
Practice Address - Country:US
Practice Address - Phone:203-571-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2025-01-30
Deactivation Date:2024-11-14
Deactivation Code:
Reactivation Date:2024-11-18
Provider Licenses
StateLicense IDTaxonomies
MALABA10001130103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst