Provider Demographics
NPI:1689875353
Name:MEDRANO, MARICELA S (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARICELA
Middle Name:S
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 1:117 E CAMELLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-9476
Mailing Address - Country:US
Mailing Address - Phone:956-563-1704
Mailing Address - Fax:888-317-8843
Practice Address - Street 1:804 PECAN BLVD STE 8
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2453
Practice Address - Country:US
Practice Address - Phone:956-563-1704
Practice Address - Fax:888-317-8843
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX334371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183121601Medicaid