Provider Demographics
NPI:1376830505
Name:VISCUSO, MICHAEL J (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:VISCUSO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 NEW YORK AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4240
Mailing Address - Country:US
Mailing Address - Phone:631-351-7676
Mailing Address - Fax:
Practice Address - Street 1:92 BROADWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1328
Practice Address - Country:US
Practice Address - Phone:631-262-7855
Practice Address - Fax:631-262-7854
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist