Healthcare Provider Details

I. General information

NPI: 1528242815
Provider Name (Legal Business Name): ROBERT A MANCUSO M.S., CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 N COURT ST HANCOCK COUNTY BOARD OF EDUCATION
NEW CUMBERLAND WV
26047
US

IV. Provider business mailing address

PO BOX 1300 HANCOCK COUNTY BOARD OF EDUCATION
NEW CUMBERLAND WV
26047-1300
US

V. Phone/Fax

Practice location:
  • Phone: 304-564-3411
  • Fax: 304-564-3990
Mailing address:
  • Phone: 304-564-3411
  • Fax: 304-564-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: