Provider Demographics
NPI:1689493314
Name:PROTSAK, MARIYA VLADIMIROVNA (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARIYA
Middle Name:VLADIMIROVNA
Last Name:PROTSAK
Suffix:
Gender:F
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:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:CLARYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12725-0152
Mailing Address - Country:US
Mailing Address - Phone:631-912-5609
Mailing Address - Fax:
Practice Address - Street 1:5 TRIANGLE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-3368
Practice Address - Country:US
Practice Address - Phone:845-551-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034271-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist