Provider Demographics
NPI:1568602399
Name:MAULDIN, MICHAEL A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:MAULDIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 ANYA RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8581
Mailing Address - Country:US
Mailing Address - Phone:575-937-6458
Mailing Address - Fax:
Practice Address - Street 1:154 ANYA RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048
Practice Address - Country:US
Practice Address - Phone:575-937-6458
Practice Address - Fax:575-257-5037
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23088103T00000X
NM1072103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist