Provider Demographics
NPI:1013264746
Name:FUSCO, NICOLE ERIN (MA, CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ERIN
Last Name:FUSCO
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:ERIN
Other - Last Name:CUNETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP, TSSLD
Mailing Address - Street 1:144 MAYSTRIK AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-3150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3029
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTSSLD 1301706390200000X
NY022589235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program