Provider Demographics
NPI:1356635791
Name:MALDONADO, LUIS ANTONIO
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ANTONIO
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 E. ORANGEBURG
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-602-8910
Mailing Address - Fax:
Practice Address - Street 1:916 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5417
Practice Address - Country:US
Practice Address - Phone:209-550-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health