MEDICARE: SANDRA MANCUSO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1750693362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA MANCUSO

Provider Business Mailing Address
First Line	:	1607 W HOWARD ST
Second Line	:	3 FL
City	:	CHICAGO
State	:	IL
Zip	:	60626-1675
Country	:	US
Telephone Number	:	312-744-7617
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 W HOWARD ST
Second Line	:	3 FL
City	:	CHICAGO
State	:	IL
Zip	:	60626-1675
Country	:	US
Telephone Number	:	312-744-7617
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2010
Last Update Date	:	07/12/2010

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Directions to “ SANDRA MANCUSO ” Practice Location

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