Provider Demographics
NPI:1235560558
Name:MEDINA, MIRIAM (MS/SLP)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:MEDINA
Suffix:
Gender:
Credentials:MS/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11724 CRANBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-5756
Mailing Address - Country:US
Mailing Address - Phone:407-729-8498
Mailing Address - Fax:
Practice Address - Street 1:11724 CRANBOURNE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-5756
Practice Address - Country:US
Practice Address - Phone:407-729-8498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14184235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1235560558Medicaid