Provider Demographics
NPI:1306616008
Name:RODRIGUEZ MEDINA, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:RODRIGUEZ 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 1:23473 SW 113TH PASS
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7155
Mailing Address - Country:US
Mailing Address - Phone:754-272-8905
Mailing Address - Fax:
Practice Address - Street 1:23473 SW 113TH PASS
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-7155
Practice Address - Country:US
Practice Address - Phone:754-272-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-317015106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty