Provider Demographics
NPI:1548523707
Name:MANCUSO, NAOMI M
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:M
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:MA
Mailing Address - Zip Code:01504-1214
Mailing Address - Country:US
Mailing Address - Phone:508-883-3179
Mailing Address - Fax:
Practice Address - Street 1:15 SOUTH ST
Practice Address - Street 2:SUITE B
Practice Address - City:HUDSON
Practice Address - State:MA
Practice Address - Zip Code:01749-2205
Practice Address - Country:US
Practice Address - Phone:508-298-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist