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General NPI Number Information
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NPI Number | 1053117093
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Entity Type | Individual
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Provider Name | KEILA MEDINA NCSP
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Gender | Female
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Dates
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Enumeration Date | 02/20/2025
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 400 TENAFLY RD UNIT 1092
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City | TENAFLY
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State | NJ
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Zip | 07670-7052
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Country | US
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Telephone | 201-777-4557
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Fax |
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Provider Business Mailing Address
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Address Line | 2618 NEW YORK AVE APT 3
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City | UNION CITY
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State | NJ
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Zip | 07087-4640
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Country | US
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Telephone | 201-647-4668
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 1148850
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License Number State | NJ
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