Provider Demographics
NPI:1154033124
Name:MALDONADO, EMMANUELLE SR (SWC)
Entity type:Individual
Prefix:
First Name:EMMANUELLE
Middle Name:
Last Name:MALDONADO
Suffix:SR
Gender:M
Credentials:SWC
Other - Prefix:MR
Other - First Name:EMMANUELLE
Other - Middle Name:
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SW
Mailing Address - Street 1:COUNTRY CLUB CALLE LLAUSETINA NUM 936
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924
Mailing Address - Country:US
Mailing Address - Phone:178-738-7541
Mailing Address - Fax:
Practice Address - Street 1:COUNTRY CLUB CALLE LLAUSETINA NUM 936
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:787-387-5419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR127951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12795OtherSOCIAL WORK