Provider Demographics
NPI:1710655915
Name:MALDONADO, EDUARDO JOSE
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:JOSE
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N IVERSON ST APT 302
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-6835
Mailing Address - Country:US
Mailing Address - Phone:954-793-3305
Mailing Address - Fax:
Practice Address - Street 1:13835 GULLANE DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-1461
Practice Address - Country:US
Practice Address - Phone:703-678-9497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-32126106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician