Provider Demographics
NPI:1083484687
Name:GENDUSO, ALYSSA ROSE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ROSE
Last Name:GENDUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MONTE CT
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-8406
Mailing Address - Country:US
Mailing Address - Phone:631-682-6491
Mailing Address - Fax:
Practice Address - Street 1:17 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4000
Practice Address - Country:US
Practice Address - Phone:631-682-6491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033258-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist