Provider Demographics
NPI:1588874614
Name:GROSSO, ANTHONY LUKE (OTRL)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:LUKE
Last Name:GROSSO
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2131
Mailing Address - Country:US
Mailing Address - Phone:631-431-6388
Mailing Address - Fax:
Practice Address - Street 1:281 N PARK DR
Practice Address - Street 2:
Practice Address - City:N MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2131
Practice Address - Country:US
Practice Address - Phone:631-431-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009488-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist