MEDICARE: CHRYSTLE MEDINA

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	103K00000X	Behavior Analyst	1-18-29595

General Provider Information

NPI Number	:	1255817235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRYSTLE MEDINA

Provider Business Mailing Address
First Line	:	2636 N SALISBURY BLVD # 1032
Second Line	:
City	:	SALISBURY
State	:	MD
Zip	:	21801-2141
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 N DIVISION ST STE 2A
Second Line	:
City	:	SALISBURY
State	:	MD
Zip	:	21801-5039
Country	:	US
Telephone Number	:	661-478-9586
Fax Number	:

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

Provider Enumeration Date	:	07/13/2018
Last Update Date	:	01/25/2023

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Directions to “ CHRYSTLE MEDINA ” Practice Location

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