Provider Demographics
NPI:1497365142
Name:MANSOUR, CONSUELA
Entity Type:Individual
Prefix:
First Name:CONSUELA
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 ELM ST APT 3
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5427
Mailing Address - Country:US
Mailing Address - Phone:617-504-9037
Mailing Address - Fax:
Practice Address - Street 1:780 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3908
Practice Address - Country:US
Practice Address - Phone:617-469-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program