Provider Demographics
NPI:1629772124
Name:MALDONADO, MYRIAM MERCEDES
Entity Type:Individual
Prefix:
First Name:MYRIAM
Middle Name:MERCEDES
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 1:4957 PALM WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-8132
Mailing Address - Country:US
Mailing Address - Phone:561-385-1504
Mailing Address - Fax:
Practice Address - Street 1:4957 PALM WAY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-8132
Practice Address - Country:US
Practice Address - Phone:561-385-1504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-265147106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician