Healthcare Provider Details

I. General information

NPI: 1700949047
Provider Name (Legal Business Name): LISA DAWN MALDONADO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. LISA DAWN DUNAWAY

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 PERKINS CREEK DR.
PADUCAH KY
42001
US

IV. Provider business mailing address

2620 PERKINS CREEK DR.
PADUCAH KY
42001
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-8465
  • Fax: 618-997-8214
Mailing address:
  • Phone: 270-444-8465
  • Fax: 618-997-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.014874
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: