Provider Demographics
NPI:1134376676
Name:TERESI, MAIA ANGELA (CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:MAIA
Middle Name:ANGELA
Last Name:TERESI
Suffix:
Gender:F
Credentials:CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BLUE SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2601
Mailing Address - Country:US
Mailing Address - Phone:585-425-8119
Mailing Address - Fax:
Practice Address - Street 1:1000 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3042
Practice Address - Country:US
Practice Address - Phone:585-271-0761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014274235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist