Provider Demographics
NPI:1487274858
Name:MANCUSO, MONICA WREN BABCOCK (MPH, RD)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:WREN BABCOCK
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:WREN
Other - Last Name:BABCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPH, RD
Mailing Address - Street 1:30680 GLENMUER ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1027
Mailing Address - Country:US
Mailing Address - Phone:248-860-4853
Mailing Address - Fax:
Practice Address - Street 1:1760 KIRTS BLVD APT 107
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4342
Practice Address - Country:US
Practice Address - Phone:248-860-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86068236133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered