Provider Demographics
NPI:1609582451
Name:MANCUSO, MATT (LMHCA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 236TH ST SW APT 208
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-4986
Mailing Address - Country:US
Mailing Address - Phone:334-790-8527
Mailing Address - Fax:
Practice Address - Street 1:7902 168TH AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4445
Practice Address - Country:US
Practice Address - Phone:508-663-3852
Practice Address - Fax:508-492-2963
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61386375101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health