Provider Demographics
NPI:1750644209
Name:BORRUSO, ROBERT ANTHONY (ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ANTHONY
Last Name:BORRUSO
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 AVE B
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779
Mailing Address - Country:US
Mailing Address - Phone:631-580-0026
Mailing Address - Fax:
Practice Address - Street 1:1 FALCON PL
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3205
Practice Address - Country:US
Practice Address - Phone:631-835-2962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001812-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer