Provider Demographics
NPI:1730663261
Name:MORENO MALDONADO, KATIA (MA)
Entity Type:Individual
Prefix:MS
First Name:KATIA
Middle Name:
Last Name:MORENO 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:W22 CALLE LEALTAD
Mailing Address - Street 2:4TA SECCION LEVITTOWN
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949
Mailing Address - Country:US
Mailing Address - Phone:787-704-0705
Mailing Address - Fax:787-744-7444
Practice Address - Street 1:CONSOLIDATED MALL B5
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726-9809
Practice Address - Country:US
Practice Address - Phone:787-704-0705
Practice Address - Fax:787-744-7444
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR23629OtherMSW