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General NPI Number Information
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NPI Number | 1780171140
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Entity Type | Individual
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Provider Name | MATTHEW CHARLES MANCUSO MSW, LMSW
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Gender | Male
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Dates
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Enumeration Date | 04/20/2018
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Last Update Date | 04/20/2018
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Provider Practice Location Address
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Address Line | 10000 BAY PINES BLVD
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City | BAY PINES
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State | FL
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Zip | 33744-8200
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Country | US
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Telephone | 727-398-6661
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Fax |
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Provider Business Mailing Address
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Address Line | 4936 MIRAMAR DR UNIT 4205
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City | MADEIRA BEACH
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State | FL
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Zip | 33708-3397
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Country | US
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Telephone | 845-641-2254
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 12529
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License Number State | SC
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