Healthcare Provider Details

I. General information

NPI: 1417478827
Provider Name (Legal Business Name): GILBERTO MALDONADO LICSWA, CDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6334 LITTLEROCK RD SW
TUMWATER WA
98512-7332
US

IV. Provider business mailing address

3808 CAMERON DR NE
LACEY WA
98516-3888
US

V. Phone/Fax

Practice location:
  • Phone: 360-704-7590
  • Fax:
Mailing address:
  • Phone: 360-628-9205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60618670
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number60616317
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: