Provider Demographics
NPI:1356586945
Name:MANCUSO, SUSAN J (OTR)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OLD ROUTE 7
Mailing Address - Street 2:ATTN CREDENTIALING DEPT
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:150 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2026
Practice Address - Country:US
Practice Address - Phone:860-456-2232
Practice Address - Fax:860-456-2256
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114979226OtherGROUP NPI NUMBER