Healthcare Provider Details

I. General information

NPI: 1265203707
Provider Name (Legal Business Name): MELISSA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 W SWANN AVE STE 200
TAMPA FL
33606-2478
US

IV. Provider business mailing address

2111 W SWANN AVE STE 200
TAMPA FL
33606-2478
US

V. Phone/Fax

Practice location:
  • Phone: 813-251-1618
  • Fax:
Mailing address:
  • Phone: 813-251-1618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-321008
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: