MEDICARE: LUISA ALEJANDRA YDROVO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	101YP2500X	Professional Counselor	A13579	NC

General Provider Information

NPI Number	:	1093225500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUISA ALEJANDRA YDROVO

Provider Business Mailing Address
First Line	:	264 WOOD DUCK RUN
Second Line	:
City	:	LEXINGTON
State	:	NC
Zip	:	27295-8263
Country	:	US
Telephone Number	:	336-880-0276
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 REYNOLDA RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-4626
Country	:	US
Telephone Number	:	336-291-7477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	03/17/2018

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