Healthcare Provider Details

I. General information

NPI: 1003525601
Provider Name (Legal Business Name): ROOSEVELT MALDONADO LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WATERMAN AVE # 224
EAST PROVIDENCE RI
02914-4305
US

IV. Provider business mailing address

105 WATERMAN AVE # 224
EAST PROVIDENCE RI
02914-4305
US

V. Phone/Fax

Practice location:
  • Phone: 401-585-3435
  • Fax:
Mailing address:
  • Phone: 401-585-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW02822
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: