Healthcare Provider Details

I. General information

NPI: 1356270664
Provider Name (Legal Business Name): MICHELLE MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CONCOURS STE 4102
ONTARIO CA
91764-6564
US

IV. Provider business mailing address

2920 S CASTLE HARBOUR PL
ONTARIO CA
91761-7239
US

V. Phone/Fax

Practice location:
  • Phone: 909-240-1764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: