Provider Demographics
NPI:1386382372
Name:MEDRANO, MICHAEL REYES (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:REYES
Last Name:MEDRANO
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17014 W BELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:415-252-7176
Practice Address - Street 1:17014 W BELL RD STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2479
Practice Address - Country:US
Practice Address - Phone:623-866-4484
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPSY-2022-0046103TC0700X
AZPSY-005525103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical