Provider Demographics
NPI:1437662210
Name:MALDONADO, ILEANA
Entity Type:Individual
Prefix:
First Name:ILEANA
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 1:189 LINCOLNDALE DR
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-1162
Mailing Address - Country:US
Mailing Address - Phone:203-519-4638
Mailing Address - Fax:
Practice Address - Street 1:79 BEACON ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-3424
Practice Address - Country:US
Practice Address - Phone:203-574-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor