Basic Information
| Provider Information | |||||||||
| NPI: | 1376060541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | RAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
| FaxNumber: | 3232322366 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 E 111TH PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900591518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2017 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.