Provider Demographics
NPI:1619018876
Name:MIDDLEBY, MARIA THERESA (MS CCCA NY STATE LIC)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:THERESA
Last Name:MIDDLEBY
Suffix:
Gender:F
Credentials:MS CCCA NY STATE LIC
Other - Prefix:MISS
Other - First Name:MARIA
Other - Middle Name:THERESA
Other - Last Name:LEONBRUNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCCA NY STATE LIC
Mailing Address - Street 1:624 BLACK RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-4326
Mailing Address - Country:US
Mailing Address - Phone:315-336-7250
Mailing Address - Fax:315-336-7254
Practice Address - Street 1:624 BLACK RIVER BLVD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-4326
Practice Address - Country:US
Practice Address - Phone:315-336-7250
Practice Address - Fax:315-336-7254
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000005549231HA2500X
NY000784231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01140050Medicaid
NY01140050Medicaid