Healthcare Provider Details

I. General information

NPI: 1497128110
Provider Name (Legal Business Name): CRYSTAL U MEDRANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 N FARWELL AVE
MILWAUKEE WI
53202-1806
US

IV. Provider business mailing address

3816 W PARK HILL AVE
MILWAUKEE WI
53208-3725
US

V. Phone/Fax

Practice location:
  • Phone: 414-225-4460
  • Fax: 414-225-4475
Mailing address:
  • Phone: 414-530-8118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: