Provider Demographics
NPI:1295329241
Name:MALDONADO, TRAKIDA (LPC)
Entity type:Individual
Prefix:
First Name:TRAKIDA
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 FAIRWAY CLOSE TER
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6027
Mailing Address - Country:US
Mailing Address - Phone:678-200-6644
Mailing Address - Fax:888-876-6566
Practice Address - Street 1:1950 FAIRWAY CLOSE TER
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6027
Practice Address - Country:US
Practice Address - Phone:678-200-6644
Practice Address - Fax:888-876-6566
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007592101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC007592OtherLICENSE
15061994OtherCAQH