Healthcare Provider Details

I. General information

NPI: 1750165502
Provider Name (Legal Business Name): LAURA MALDONADO SLPA, THL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 CRESCENT PARK DR
RIVERVIEW FL
33578-3605
US

IV. Provider business mailing address

12746 MAPLE BONSAI DR
RIVERVIEW FL
33579-9444
US

V. Phone/Fax

Practice location:
  • Phone: 813-492-8310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI5604
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: