Provider Demographics
NPI:1376980201
Name:MANCUSO, CAROLINE LIESELL (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:LIESELL
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9659 MOSS ROSE CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-6437
Mailing Address - Country:US
Mailing Address - Phone:720-253-7985
Mailing Address - Fax:
Practice Address - Street 1:5347 S VALENTIA WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-3107
Practice Address - Country:US
Practice Address - Phone:720-253-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-02
Last Update Date:2013-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSTATE LICENSE PENDIN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist