Provider Demographics
NPI:1609365725
Name:BORISUCK, ONEIDA (LMT# MA66416)
Entity Type:Individual
Prefix:
First Name:ONEIDA
Middle Name:
Last Name:BORISUCK
Suffix:
Gender:F
Credentials:LMT# MA66416
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 NW 19TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-4078
Mailing Address - Country:US
Mailing Address - Phone:754-317-0182
Mailing Address - Fax:
Practice Address - Street 1:195 GIRALDA AVE STE M
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5208
Practice Address - Country:US
Practice Address - Phone:754-317-0182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA66416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist