Provider Demographics
NPI:1477522043
Name:MANCUSO, GWEN
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 TIDEWAY DR
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3511
Mailing Address - Country:US
Mailing Address - Phone:510-375-6234
Mailing Address - Fax:
Practice Address - Street 1:304 TIDEWAY DR
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3511
Practice Address - Country:US
Practice Address - Phone:510-375-6234
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA812190171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17OtherHOMEMAKER CARE