Provider Demographics
NPI:1609355155
Name:MALDONADO, LUIS JESUS (AOD COUNSELOR)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:JESUS
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:AOD COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1326
Mailing Address - Country:US
Mailing Address - Phone:310-314-6200
Mailing Address - Fax:
Practice Address - Street 1:909 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1326
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA179970101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)