Provider Demographics
NPI:1700774593
Name:MEDINA CAMPUSANO, IVONNE MARIA
Entity type:Individual
Prefix:MRS
First Name:IVONNE
Middle Name:MARIA
Last Name:MEDINA CAMPUSANO
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:IVONNE
Other - Middle Name:
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD, CPL
Mailing Address - Street 1:316 CALLE GERONA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00923-1908
Mailing Address - Country:US
Mailing Address - Phone:787-554-5605
Mailing Address - Fax:
Practice Address - Street 1:124 AVE FRANKLIN D ROOSEVELT # 124
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-2409
Practice Address - Country:US
Practice Address - Phone:787-554-5605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004713101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional