Provider Demographics
NPI:1770155780
Name:MEDRANO, LIDIA BALDERAS
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:BALDERAS
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W BROADWAY STE 1925
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8505
Mailing Address - Country:US
Mailing Address - Phone:619-746-7031
Mailing Address - Fax:
Practice Address - Street 1:402 W BROADWAY STE 1925
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-8505
Practice Address - Country:US
Practice Address - Phone:619-322-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool