Provider Demographics
NPI:1760938740
Name:MALDONADO, CRISTAL RODRIGUEZ
Entity type:Individual
Prefix:
First Name:CRISTAL
Middle Name:RODRIGUEZ
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-2613
Mailing Address - Country:US
Mailing Address - Phone:209-559-9352
Mailing Address - Fax:
Practice Address - Street 1:56 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3100
Practice Address - Country:US
Practice Address - Phone:209-662-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147704106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist