Provider Demographics
NPI:1366860900
Name:MANCUSO, HEATHER (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:PENNIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:328 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3795
Mailing Address - Country:US
Mailing Address - Phone:508-519-3513
Mailing Address - Fax:
Practice Address - Street 1:328 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-3795
Practice Address - Country:US
Practice Address - Phone:508-519-3513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MA13028-MH-CC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor