Provider Demographics
NPI:1881044220
Name:MALDONADO, LILLIE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:
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 1:804 SARAH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-1739
Mailing Address - Country:US
Mailing Address - Phone:570-422-6522
Mailing Address - Fax:570-422-6524
Practice Address - Street 1:804 SARAH ST STE 305
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-1739
Practice Address - Country:US
Practice Address - Phone:570-422-6522
Practice Address - Fax:570-422-6524
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA457047101YA0400X
NY18746101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18746OtherCASAC,BHS,PROGRAM DIRECTOR,CLINICAL
PA457047OtherDDAP