Basic Information
| Provider Information | |||||||||
| NPI: | 1427561927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 CLAFLIN RD | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855874300 | ||||||||
| FaxNumber: | 7855874363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1558 HAYES DR | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855874300 | ||||||||
| FaxNumber: | 7855874315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2017 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1550 | KS | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1009803A | 05 | KS | MEDICAID |