Healthcare Provider Details

I. General information

NPI: 1669361275
Provider Name (Legal Business Name): ANGELA NIVON MEDRANO LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AGELA NIVON MEDRANO

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S BURR ST STE 200
MITCHELL SD
57301-4586
US

IV. Provider business mailing address

2000 SHANARD RD
MITCHELL SD
57301-2186
US

V. Phone/Fax

Practice location:
  • Phone: 605-292-0361
  • Fax:
Mailing address:
  • Phone: 210-850-8486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-21089
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: