Provider Demographics
NPI:1104352731
Name:MALDONADO, MELONIE ELIZABETH (BCBA)
Entity type:Individual
Prefix:
First Name:MELONIE
Middle Name:ELIZABETH
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 ADVANA ST NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5206
Mailing Address - Country:US
Mailing Address - Phone:213-831-9656
Mailing Address - Fax:
Practice Address - Street 1:1887 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5530
Practice Address - Country:US
Practice Address - Phone:772-463-0444
Practice Address - Fax:772-219-1339
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL0-18-9206106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020780900Medicaid