Provider Demographics
NPI:1063666121
Name:DE MARIA, MICHELE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:DE MARIA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11560-1921
Mailing Address - Country:US
Mailing Address - Phone:917-282-2219
Mailing Address - Fax:
Practice Address - Street 1:12 WALNUT RD
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2227
Practice Address - Country:US
Practice Address - Phone:917-282-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-15
Last Update Date:2008-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009022-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist