Provider Demographics
NPI:1821437492
Name:FUCCILLO, PAUL J (LAC LMT MS MA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:FUCCILLO
Suffix:
Gender:M
Credentials:LAC LMT MS MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3902
Mailing Address - Country:US
Mailing Address - Phone:631-223-3385
Mailing Address - Fax:
Practice Address - Street 1:28 BIRCHWOOD DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3902
Practice Address - Country:US
Practice Address - Phone:631-223-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004701171100000X
NY024021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist