Provider Demographics
NPI:1083965586
Name:MEDRANO, MIRIAM C (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:C
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EMANCIPATION DR
Mailing Address - Street 2:BUILDING 71 RM 222
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:703-347-5503
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:BUILDING 71 RM 222
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:703-347-5503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040067311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical