Provider Demographics
NPI:1346708807
Name:MANCUSI, MARILYN ANNE (RADT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ANNE
Last Name:MANCUSI
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 HUDSON CT APT 46
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4030
Mailing Address - Country:US
Mailing Address - Phone:925-813-8515
Mailing Address - Fax:
Practice Address - Street 1:1915 D ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2571
Practice Address - Country:US
Practice Address - Phone:925-848-8467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1339490319101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)