MEDICARE: DR. ANGELA J MEDINA-LAGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	NO	FL
2	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1073888988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA J MEDINA-LAGO

Provider Business Mailing Address
First Line	:	2290 N RONALD REAGAN BLVD STE 116
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-3534
Country	:	US
Telephone Number	:	407-962-7953
Fax Number	:

Provider Business Practice Location Address
First Line	:	2290 N RONALD REAGAN BLVD STE 116
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-3534
Country	:	US
Telephone Number	:	407-962-7953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2012
Last Update Date	:	06/13/2024

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