Provider Demographics
NPI:1265933352
Name:MALDONADO, INGRIS (PHD)
Entity type:Individual
Prefix:DR
First Name:INGRIS
Middle Name:
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:PO BOX 450014
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34745-0014
Mailing Address - Country:US
Mailing Address - Phone:407-744-5447
Mailing Address - Fax:
Practice Address - Street 1:1209 W OAK ST STE 28
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4021
Practice Address - Country:US
Practice Address - Phone:407-744-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2712103TC1900X
PR4375101YP2500X
NJ37PC00850900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicaid