Provider Demographics
NPI:1306328018
Name:MEDINA CRESPO, GISSELLE (MSW)
Entity type:Individual
Prefix:
First Name:GISSELLE
Middle Name:
Last Name:MEDINA CRESPO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 COND ALTURAS DEL BOSQUE CARR 844 APT 1104
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-7860
Mailing Address - Country:US
Mailing Address - Phone:787-615-7875
Mailing Address - Fax:
Practice Address - Street 1:PARADA 37 1/2 AVENIDA PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-758-2000
Practice Address - Fax:787-771-7966
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11636104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker