Provider Demographics
NPI:1710017330
Name:MALDONADO, ELISA M (MA)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:M
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9430 E NEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-1500
Mailing Address - Country:US
Mailing Address - Phone:480-635-2011
Mailing Address - Fax:480-635-2020
Practice Address - Street 1:9430 E NEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-1500
Practice Address - Country:US
Practice Address - Phone:480-635-2011
Practice Address - Fax:480-635-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM299218103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool