Provider Demographics
NPI:1104583095
Name:MALDONADO, TIMOTHY W
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:W
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1622
Mailing Address - Country:US
Mailing Address - Phone:559-251-4800
Mailing Address - Fax:559-453-7827
Practice Address - Street 1:2772 S. M.L. .K JR. BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA14949101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)