Provider Demographics
NPI:1407390602
Name:MEDRANO, AUDREY (LCSW)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:MEDRANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:184 UNSER BLVD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4045
Mailing Address - Country:US
Mailing Address - Phone:505-261-8317
Mailing Address - Fax:
Practice Address - Street 1:184 UNSER BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-896-0928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-096821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical