Provider Demographics
NPI:1366762403
Name:MEDINA, ELAINE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:URDANETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16405 SW 72ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3700
Mailing Address - Country:US
Mailing Address - Phone:305-801-0286
Mailing Address - Fax:
Practice Address - Street 1:16405 SW 72ND TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193
Practice Address - Country:US
Practice Address - Phone:305-801-0286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16131235Z00000X
FLSZ7980235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty