Provider Demographics
NPI:1932984804
Name:MEDINA, KIMBERLY MARIE (MSC)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-0536
Mailing Address - Country:US
Mailing Address - Phone:787-705-5565
Mailing Address - Fax:
Practice Address - Street 1:PR 1 AVE. SAKURA, BAIROA, VILLA BLANCA INDUSTRIAL PARK
Practice Address - Street 2:SEGUNDO PISO SUITE 235
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-705-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7716103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling