Provider Demographics
NPI:1053117093
Name:MEDINA, KEILA (NCSP)
Entity type:Individual
Prefix:
First Name:KEILA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 NEW YORK AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-4640
Mailing Address - Country:US
Mailing Address - Phone:201-647-4668
Mailing Address - Fax:
Practice Address - Street 1:400 TENAFLY RD UNIT 1092
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-7052
Practice Address - Country:US
Practice Address - Phone:201-777-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NJ1148850103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No251S00000XAgenciesCommunity/Behavioral Health