Provider Demographics
NPI:1982323184
Name:BROCKWAY, MARIS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARIS
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 COUNTY ROUTE 46
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-3315
Mailing Address - Country:US
Mailing Address - Phone:315-250-8309
Mailing Address - Fax:
Practice Address - Street 1:10 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1019
Practice Address - Country:US
Practice Address - Phone:315-769-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-10-05
Deactivation Date:2022-09-01
Deactivation Code:
Reactivation Date:2022-10-05
Provider Licenses
StateLicense IDTaxonomies
NY049346-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist