MEDICARE: CRYSTAL U MEDRANO

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	1041C0700X	Clinical Social Worker		WI

General Provider Information

NPI Number	:	1497128110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL U MEDRANO

Provider Business Mailing Address
First Line	:	3816 W PARK HILL AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-3725
Country	:	US
Telephone Number	:	414-530-8118
Fax Number	:

Provider Business Practice Location Address
First Line	:	1744 N FARWELL AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-1806
Country	:	US
Telephone Number	:	414-225-4460
Fax Number	:	414-225-4475

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

Provider Enumeration Date	:	11/03/2015
Last Update Date	:	11/03/2015

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