Provider Demographics
NPI:1447434709
Name:MCCONNEGHEY, MARITZAM MARICE (PHD)
Entity type:Individual
Prefix:PROF
First Name:MARITZAM
Middle Name:MARICE
Last Name:MCCONNEGHEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARITZA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1138 229TH DR S
Mailing Address - Street 2:6G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-5119
Mailing Address - Country:US
Mailing Address - Phone:347-449-6790
Mailing Address - Fax:347-665-1477
Practice Address - Street 1:1138 229TH DR S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-5119
Practice Address - Country:US
Practice Address - Phone:718-992-1573
Practice Address - Fax:347-665-1477
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2030100222Q00000X
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02799640Medicaid
NY40948101OtherUSMLE
NYW07048422COtherDEA