Basic Information
| Provider Information | |||||||||
| NPI: | 1891831772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEXIDOR-MALDONADO | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | OBED | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CADC II, CGAC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 NEOTA ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973012185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034091906 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2035 DAVCOR ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035764660 | ||||||||
| FaxNumber: | 5033612688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 06-07-67 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | G 09-12-06 | OR | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.