Provider Demographics
NPI:1235880014
Name:MAIRA, CARLY JANE (MS)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JANE
Last Name:MAIRA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 DEER MEADOW RUN
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502
Mailing Address - Country:US
Mailing Address - Phone:585-683-5464
Mailing Address - Fax:
Practice Address - Street 1:1000 ELMWOOD AVENUE SUITE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620
Practice Address - Country:US
Practice Address - Phone:585-271-0761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031522-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist