MEDICARE: MRS. LISSA ALEXANDRA MEDINA ATR

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	101YM0800X	Mental Health Counselor
2	221700000X	Art Therapist

General Provider Information

NPI Number	:	1437676657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISSA ALEXANDRA MEDINA ATR

Provider Business Mailing Address
First Line	:	1230 SOUTHSTATION PL UNIT 114
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-3114
Country	:	US
Telephone Number	:	917-574-1831
Fax Number	:

Provider Business Practice Location Address
First Line	:	1230 SOUTHSTATION PL UNIT 114
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-3114
Country	:	US
Telephone Number	:	917-574-1831
Fax Number	:

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

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	05/05/2026

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