Provider Demographics
NPI:1275817595
Name:MANSUETTO, MARY AILEEN (MA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:AILEEN
Last Name:MANSUETTO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 E COVE AVE UNIT E
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5080
Mailing Address - Country:US
Mailing Address - Phone:304-243-5600
Mailing Address - Fax:304-905-9131
Practice Address - Street 1:98 E COVE AVE UNIT E
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5080
Practice Address - Country:US
Practice Address - Phone:304-243-5600
Practice Address - Fax:304-905-9131
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV881103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical