Provider Demographics
NPI:1790188647
Name:MEDRANO, IVAN ALDO (LMSW)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:ALDO
Last Name:MEDRANO
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8212 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1793
Mailing Address - Country:US
Mailing Address - Phone:718-848-0300
Mailing Address - Fax:718-835-2862
Practice Address - Street 1:8212 151ST AVE
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1793
Practice Address - Country:US
Practice Address - Phone:718-848-0300
Practice Address - Fax:718-835-2862
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0931321251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)