Provider Demographics
NPI:1912489204
Name:HALLBILSBACK, MARIAH CARROLL (MA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:CARROLL
Last Name:HALLBILSBACK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 46TH ST 4B
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104
Mailing Address - Country:US
Mailing Address - Phone:508-561-4247
Mailing Address - Fax:
Practice Address - Street 1:4130 46TH ST 4B
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-7063
Practice Address - Country:US
Practice Address - Phone:508-561-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095251-011041C0700X
101Y00000X
NY107600-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY095251-01OtherLCSW
NY107600-01OtherLMSW