Healthcare Provider Details

I. General information

NPI: 1750285326
Provider Name (Legal Business Name): MATTHEW MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9425 SUNSET DR STE 164
MIAMI FL
33173-3290
US

IV. Provider business mailing address

8215 SW 152ND AVE APT G-206
MIAMI FL
33193-4014
US

V. Phone/Fax

Practice location:
  • Phone: 305-279-2286
  • Fax:
Mailing address:
  • Phone: 786-913-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-26-2849383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: