Provider Demographics
NPI:1538132675
Name:MANCUSO, GINA M (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OAK LN
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2233
Mailing Address - Country:US
Mailing Address - Phone:973-857-1909
Mailing Address - Fax:
Practice Address - Street 1:354 AVENUE C
Practice Address - Street 2:PENTHOUSE SUITE
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1412
Practice Address - Country:US
Practice Address - Phone:201-535-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055544001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ310054Medicare PIN