Provider Demographics
NPI:1598324600
Name:FENOLLAL MALDONADO, GABRIELA
Entity Type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:FENOLLAL 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 1:660 SOUTH EUCLID AVENUE
Mailing Address - Street 2:MAILBOX 8504-0066-03
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-286-1700
Mailing Address - Fax:
Practice Address - Street 1:4444 FOREST PARK AVE STE 2600
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1700
Practice Address - Fax:314-747-6777
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200179272084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry