Provider Demographics
NPI:1801471024
Name:MALDONADO, LICELOTT MARIE (CLIN PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:LICELOTT
Middle Name:MARIE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:CLIN PSYCHOLOGIST
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 8930
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-8930
Mailing Address - Country:US
Mailing Address - Phone:787-638-3778
Mailing Address - Fax:
Practice Address - Street 1:450 CALLE FERROCARRIL STE 203
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-4105
Practice Address - Country:US
Practice Address - Phone:787-638-3778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical