Healthcare Provider Details

I. General information

NPI: 1104583095
Provider Name (Legal Business Name): MR. TIMOTHY W MALDONADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2772 S. M.L. .K JR. BLVD
FRESNO CA
93706
US

IV. Provider business mailing address

1900 N GATEWAY BLVD
FRESNO CA
93727-1622
US

V. Phone/Fax

Practice location:
  • Phone: 559-265-4800
  • Fax:
Mailing address:
  • Phone: 559-251-4800
  • Fax: 559-453-7827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: