Provider Demographics
NPI:1447851589
Name:BAGNASCO, EMILY NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:NICOLE
Last Name:BAGNASCO
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 1:827 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5625
Mailing Address - Country:US
Mailing Address - Phone:631-521-0892
Mailing Address - Fax:
Practice Address - Street 1:827 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5625
Practice Address - Country:US
Practice Address - Phone:631-521-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029276225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty