Provider Demographics
NPI:1780845958
Name:MANCUSO, TINA MARIA (AUD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIA
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1723
Mailing Address - Country:US
Mailing Address - Phone:303-953-5976
Mailing Address - Fax:
Practice Address - Street 1:11150 HURON ST
Practice Address - Street 2:208
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4379
Practice Address - Country:US
Practice Address - Phone:303-426-0633
Practice Address - Fax:303-426-0759
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001416-01231H00000X
CO525237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61927872Medicaid
CO61927872Medicaid