Provider Demographics
NPI:1811104094
Name:MCKEON MANCUSO, DONNA M (LCSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:MCKEON MANCUSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HALL AVENUE
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-6308
Mailing Address - Country:US
Mailing Address - Phone:845-368-1194
Mailing Address - Fax:
Practice Address - Street 1:7 HALL AVENUE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-6308
Practice Address - Country:US
Practice Address - Phone:845-368-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02669911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical