Basic Information
| Provider Information | |||||||||
| NPI: | 1295002004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | ANDREICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 NORMAN ST | ||||||||
| Address2: | |||||||||
| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010895003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137368329 | ||||||||
| FaxNumber: | 4137341651 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138460445 | ||||||||
| FaxNumber: | 4138460447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2011 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | M18463 | 01 | MA | BLUE CROSS | OTHER | 1307576 (SA) | 05 | MA | MEDICAID | 1303295 (MH) | 05 | MA | MEDICAID |