Provider Demographics
NPI:1346374758
Name:MANCUSO, STEPHANIE (RD, DC, FICPA)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:RD, DC, FICPA
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MANCUSO-RENNIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, DC, FICPA
Mailing Address - Street 1:8402 E SHEA BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6635
Mailing Address - Country:US
Mailing Address - Phone:480-219-4439
Mailing Address - Fax:480-219-4569
Practice Address - Street 1:8402 E SHEA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6635
Practice Address - Country:US
Practice Address - Phone:480-219-4439
Practice Address - Fax:480-219-4569
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5988111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0941110OtherBCBS
AZV05309Medicare UPIN
AZAZ0941110OtherBCBS