MEDICARE: ERICA MEDINE M.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP17971	CA

General Provider Information

NPI Number	:	1528415379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA MEDINE M.S

Provider Business Mailing Address
First Line	:	13360 BURBANK BLVD APT 9
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91401-5384
Country	:	US
Telephone Number	:	310-867-1145
Fax Number	:

Provider Business Practice Location Address
First Line	:	5301 LAUREL CANYON BLVD STE 245
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-2777
Country	:	US
Telephone Number	:	818-435-2960
Fax Number	:	818-435-2903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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Directions to “ ERICA MEDINE M.S” Practice Location

Language	Start Address	Practice Location

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