Healthcare Provider Details

I. General information

NPI: 1649245069
Provider Name (Legal Business Name): DONNA M MANCUSO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 ANTONINE ST SUITE 500
NEW ORLEANS LA
70115-3601
US

IV. Provider business mailing address

1301 ANTONINE STREET SUITE 500
NEW ORLEANS LA
70115
US

V. Phone/Fax

Practice location:
  • Phone: 504-208-1035
  • Fax: 504-891-3039
Mailing address:
  • Phone: 504-208-1035
  • Fax: 504-891-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number17303
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number17303
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17303
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: