Provider Demographics
NPI:1316522543
Name:MEDINA, DANIELA VERONICA
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:VERONICA
Last Name:MEDINA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 BIG SUR RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7781
Mailing Address - Country:US
Mailing Address - Phone:786-715-8687
Mailing Address - Fax:
Practice Address - Street 1:1420 CELEBRATION BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5162
Practice Address - Country:US
Practice Address - Phone:407-922-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-147782106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty