Healthcare Provider Details

I. General information

NPI: 1588087183
Provider Name (Legal Business Name): NICOLE MANCUSO ED. S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N SPRING GROVE ST
MEDINA OH
44256-1969
US

IV. Provider business mailing address

320 N SPRING GROVE ST
MEDINA OH
44256-1969
US

V. Phone/Fax

Practice location:
  • Phone: 330-636-4156
  • Fax:
Mailing address:
  • Phone: 330-636-4156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.02354
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: