Provider Demographics
NPI:1285392027
Name:MEDINA, HEATHER (BCBA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 FREE FORMED CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6168
Mailing Address - Country:US
Mailing Address - Phone:732-259-1038
Mailing Address - Fax:
Practice Address - Street 1:8020 W SAHARA AVE STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7917
Practice Address - Country:US
Practice Address - Phone:702-595-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1-21-53988103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst