Provider Demographics
NPI:1245570282
Name:MANCUSO, MARIE ANNE (PMHNP)
Entity Type:Individual
Prefix:
First Name:MARIE ANNE
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1406
Mailing Address - Country:US
Mailing Address - Phone:347-756-9400
Mailing Address - Fax:
Practice Address - Street 1:20514 LINDEN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2900
Practice Address - Country:US
Practice Address - Phone:718-528-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659896163W00000X
NY402366363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse