Basic Information
| Provider Information | |||||||||
| NPI: | 1558810747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | MAYRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 E MINARETS AVE | ||||||||
| Address2: | |||||||||
| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936501239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594360482 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 MCCALL AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936622560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553431057 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | LMFT129666 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.