Provider Demographics
NPI:1184367682
Name:MALDONADO, MIA NORA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:NORA
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 1:1501 TREE CORNERS PKWY
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-6151
Mailing Address - Country:US
Mailing Address - Phone:679-392-8629
Mailing Address - Fax:
Practice Address - Street 1:1501 TREE CORNERS PKWY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-6151
Practice Address - Country:US
Practice Address - Phone:679-392-8629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst