Provider Demographics
NPI:1396150678
Name:MANCUSO, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3152
Mailing Address - Country:US
Mailing Address - Phone:631-324-0207
Mailing Address - Fax:631-824-9050
Practice Address - Street 1:110 STEPHEN HANDS PATH
Practice Address - Street 2:
Practice Address - City:WAINSCOTT
Practice Address - State:NY
Practice Address - Zip Code:11975
Practice Address - Country:US
Practice Address - Phone:631-324-0207
Practice Address - Fax:631-824-9050
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool