Provider Demographics
NPI:1912030313
Name:MANCUSO, MICHELLE (COTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVER RD STE 112
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-4226
Mailing Address - Country:US
Mailing Address - Phone:504-828-7696
Mailing Address - Fax:504-828-8935
Practice Address - Street 1:101 RIVER RD STE 112
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-4226
Practice Address - Country:US
Practice Address - Phone:504-828-7696
Practice Address - Fax:504-828-8935
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA205952355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant