Provider Demographics
NPI:1700567773
Name:MANCUSO, ALEXANDRA (PT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W ALVA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3409
Mailing Address - Country:US
Mailing Address - Phone:336-420-9360
Mailing Address - Fax:
Practice Address - Street 1:4211 BOY SCOUT BLVD
Practice Address - Street 2:STE 450
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683
Practice Address - Country:US
Practice Address - Phone:813-892-7884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist