Provider Demographics
NPI:1780967562
Name:MAGGIACOMO, LYNN R
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:R
Last Name:MAGGIACOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3631
Mailing Address - Country:US
Mailing Address - Phone:631-289-6861
Mailing Address - Fax:
Practice Address - Street 1:159 SYRACUSE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3631
Practice Address - Country:US
Practice Address - Phone:631-289-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011160-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist