MEDICARE: CHRISTINA MARIE MALDONADO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149013156	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	149013156	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1356583603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA MARIE MALDONADO LCSW

Provider Business Mailing Address
First Line	:	5710 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4302
Country	:	US
Telephone Number	:	773-728-1000
Fax Number	:	773-765-0401

Provider Business Practice Location Address
First Line	:	5710 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4302
Country	:	US
Telephone Number	:	773-728-1000
Fax Number	:	773-765-0401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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