Healthcare Provider Details

I. General information

NPI: 1982568952
Provider Name (Legal Business Name): NICOLE LUCCISANO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7119 80TH ST STE 8213
GLENDALE NY
11385-7733
US

IV. Provider business mailing address

7119 80TH ST STE 8213
GLENDALE NY
11385-7733
US

V. Phone/Fax

Practice location:
  • Phone: 347-639-7969
  • Fax:
Mailing address:
  • Phone: 347-639-7969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: