Provider Demographics
NPI:1548664758
Name:DELUCA, TIMOTHY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:DELUCA
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 LAKE ST # 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3825
Mailing Address - Country:US
Mailing Address - Phone:516-361-4521
Mailing Address - Fax:
Practice Address - Street 1:193 OAK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1457
Practice Address - Country:US
Practice Address - Phone:516-361-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist