Provider Demographics
NPI:1376927368
Name:MALDONADO, MARISA GRACE (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:GRACE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8503 HONILEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-2206
Mailing Address - Country:US
Mailing Address - Phone:210-219-2516
Mailing Address - Fax:
Practice Address - Street 1:1020 CENTRAL PKWY S
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-5021
Practice Address - Country:US
Practice Address - Phone:210-798-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116887251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services