Healthcare Provider Details

I. General information

NPI: 1780171140
Provider Name (Legal Business Name): MATTHEW CHARLES MANCUSO MSW, LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BAY PINES BLVD
BAY PINES FL
33744-8200
US

IV. Provider business mailing address

4936 MIRAMAR DR UNIT 4205
MADEIRA BEACH FL
33708-3397
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-6661
  • Fax:
Mailing address:
  • Phone: 845-641-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12529
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: