Provider Demographics
NPI:1477139483
Name:GIRALDO, MAURICIO H (MT)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:H
Last Name:GIRALDO
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6124 DURHAM AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-3410
Mailing Address - Country:US
Mailing Address - Phone:917-496-9640
Mailing Address - Fax:
Practice Address - Street 1:6124 DURHAM AVE APT 1
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-3410
Practice Address - Country:US
Practice Address - Phone:917-496-9640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00143800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ833954663Medicaid