Provider Demographics
NPI:1639458169
Name:MEDRANO, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2007
Mailing Address - Country:US
Mailing Address - Phone:408-841-4109
Mailing Address - Fax:
Practice Address - Street 1:2226 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2007
Practice Address - Country:US
Practice Address - Phone:408-841-4109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)