Healthcare Provider Details

I. General information

NPI: 1942676937
Provider Name (Legal Business Name): MARCELA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4835 SW 111TH AVE
MIAMI FL
33165-6132
US

IV. Provider business mailing address

4835 SW 111TH AVE
MIAMI FL
33165-6132
US

V. Phone/Fax

Practice location:
  • Phone: 786-301-8476
  • Fax: 786-301-8476
Mailing address:
  • Phone: 786-624-9329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW15365
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24606
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number50081938
License Number StateDC
# 5
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number50081938
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: