Provider Demographics
NPI:1235697798
Name:MALDONADO, MILLICENT
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:
Last Name:MALDONADO
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 1:185 CALLE COSTA RICA APT 502
Mailing Address - Street 2:COND TEIDE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917
Mailing Address - Country:US
Mailing Address - Phone:939-202-9296
Mailing Address - Fax:
Practice Address - Street 1:988 AVE LUIS MUNOZ RIVERA
Practice Address - Street 2:URB HYDE PARK
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927
Practice Address - Country:US
Practice Address - Phone:939-202-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6075103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist