Provider Demographics
NPI:1902453699
Name:MAILLIS, STACIA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:MAILLIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:STACIA
Other - Middle Name:
Other - Last Name:MAILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:520 FRANKLIN AVE STE L6E
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5813
Mailing Address - Country:US
Mailing Address - Phone:516-477-5192
Mailing Address - Fax:
Practice Address - Street 1:520 FRANKLIN AVE STE L6E
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5813
Practice Address - Country:US
Practice Address - Phone:516-477-5192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist