Provider Demographics
NPI:1518009679
Name:MANCUSO, ROBERT P (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:P
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2136
Mailing Address - Country:US
Mailing Address - Phone:516-317-9929
Mailing Address - Fax:
Practice Address - Street 1:881 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2136
Practice Address - Country:US
Practice Address - Phone:516-317-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR054916-1OtherLCSW