Provider Demographics
NPI:1477852754
Name:MANCUSO, KEELEE RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:KEELEE
Middle Name:RAE
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KEELEE
Other - Middle Name:RAE
Other - Last Name:KIEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:8810 RIO SAN DIEGO DR STE 2200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1698
Mailing Address - Country:US
Mailing Address - Phone:858-774-0003
Mailing Address - Fax:
Practice Address - Street 1:8810 RIO SAN DIEGO DR STE 2200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1698
Practice Address - Country:US
Practice Address - Phone:858-774-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical