Healthcare Provider Details

I. General information

NPI: 1609654805
Provider Name (Legal Business Name): ANGIE DIANNA MALDONADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax: 626-585-1664
Mailing address:
  • Phone: 626-798-6793
  • Fax: 626-585-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: