Provider Demographics
NPI:1720602675
Name:MALDONADO, AMANDA GRACIELA (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACIELA
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 CALLE ORQUIDEA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-6714
Mailing Address - Country:US
Mailing Address - Phone:787-430-4031
Mailing Address - Fax:
Practice Address - Street 1:1909 CALLE ORQUIDEA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-6714
Practice Address - Country:US
Practice Address - Phone:787-430-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1785103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty