Provider Demographics
NPI:1245865898
Name:MANCUSO, NICOLE (MHA)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2121
Mailing Address - Country:US
Mailing Address - Phone:570-253-3980
Mailing Address - Fax:
Practice Address - Street 1:1855 FAIR AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2121
Practice Address - Country:US
Practice Address - Phone:570-253-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA647010251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health