Provider Demographics
NPI:1669048625
Name:FUSCO, KENNETH PATRICK (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PATRICK
Last Name:FUSCO
Suffix:
Gender:M
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 REDMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6810
Mailing Address - Country:US
Mailing Address - Phone:631-968-0105
Mailing Address - Fax:
Practice Address - Street 1:354 VETERANS MEMORIAL HWY STE 3
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4331
Practice Address - Country:US
Practice Address - Phone:516-220-1049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-44448103K00000X
106S00000X
NY002466103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician