Provider Demographics
NPI:1912316514
Name:MALDONADO, MARITZA (BA,LMT)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:BA,LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 WIMBLEDON DR
Mailing Address - Street 2:
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-9115
Mailing Address - Country:US
Mailing Address - Phone:847-487-5039
Mailing Address - Fax:
Practice Address - Street 1:2604 W JOHNSBURG RD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-5105
Practice Address - Country:US
Practice Address - Phone:815-578-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.003094225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist