Provider Demographics
NPI:1801194766
Name:RESASCO, KATHY ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:ANNE
Last Name:RESASCO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-0013
Mailing Address - Country:US
Mailing Address - Phone:631-737-2070
Mailing Address - Fax:631-737-2070
Practice Address - Street 1:60 LORRAINE CT
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1540
Practice Address - Country:US
Practice Address - Phone:631-737-2070
Practice Address - Fax:631-737-2070
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist