Provider Demographics
NPI:1053817288
Name:MEDRANO, GRACE (MFTI)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W WASHINGTON ST STE 2-940
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1946
Mailing Address - Country:US
Mailing Address - Phone:559-556-0849
Mailing Address - Fax:
Practice Address - Street 1:3344 4TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5704
Practice Address - Country:US
Practice Address - Phone:559-556-0849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103806106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103806OtherREGISTERED INTERN NUMBER