Healthcare Provider Details

I. General information

NPI: 1912316514
Provider Name (Legal Business Name): MARITZA MALDONADO B.A,L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 W JOHNSBURG RD
JOHNSBURG IL
60051-5105
US

IV. Provider business mailing address

1025 WIMBLEDON DR
ISLAND LAKE IL
60042-9115
US

V. Phone/Fax

Practice location:
  • Phone: 815-578-1771
  • Fax:
Mailing address:
  • Phone: 847-487-5039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.003094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: