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 1:129A HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2305
Mailing Address - Country:US
Mailing Address - Phone:516-742-5243
Mailing Address - Fax:
Practice Address - Street 1:129A HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2305
Practice Address - Country:US
Practice Address - Phone:516-742-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist