Provider Demographics
NPI:1336268713
Name:MALDONADO, MARIO DAVID (TBS)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:DAVID
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:TBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 15TH ST W SPC 76
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:CA
Mailing Address - Zip Code:93560-7316
Mailing Address - Country:US
Mailing Address - Phone:661-256-8108
Mailing Address - Fax:
Practice Address - Street 1:921 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0131
Practice Address - Fax:661-729-8912
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR00007473Medicaid
CACBSC760OtherLA DMH PROVIDER