Individual
ANDREA JENNYS SUSTACHE MEDINA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3813 PERIWINKLE DR, FORT WORTH, TX 76137-6046
(787) 983-4456
Mailing address
3813 PERIWINKLE DR, FORT WORTH, TX 76137-6046
(787) 983-4456
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
117625
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
659249401
—
TX
Enumeration date
06/02/2022
Last updated
06/02/2022
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