Provider Demographics
NPI:1548932171
Name:MEDRANO, KEENA LUCINDIVINE PAGARAN
Entity type:Individual
Prefix:
First Name:KEENA LUCINDIVINE
Middle Name:PAGARAN
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KEENA LUCINDIVINE
Other - Middle Name:MEDRANO
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:225 CEDAR HILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-5900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 MILAM ST STE 1300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-2736
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TXRBT-21-164317106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician