=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700774593
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. IVONNE MARIA MEDINA CAMPUSANO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2025
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 AVE FRANKLIN D ROOSEVELT # 124
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-554-5605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 CALLE GERONA
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00923-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-554-5605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 004713
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------