MEDICARE: BRISEYDA 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	106S00000X	Behavior Technician		CA

General Provider Information

NPI Number	:	1780338319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRISEYDA MEDINA

Provider Business Mailing Address
First Line	:	5368 INGLEWOOD BLVD # 3
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-5951
Country	:	US
Telephone Number	:	833-831-8946
Fax Number	:	833-831-8946

Provider Business Practice Location Address
First Line	:	5368 INGLEWOOD BLVD # 3
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-5951
Country	:	US
Telephone Number	:	833-831-8946
Fax Number	:	833-831-8946

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

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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Directions to “ BRISEYDA MEDINA ” Practice Location

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