Provider Demographics
NPI:1730105537
Name:MANCUSO, EILEEN (PT)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 JFK DR
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-1651
Mailing Address - Country:US
Mailing Address - Phone:732-846-5852
Mailing Address - Fax:
Practice Address - Street 1:31 JFK DR
Practice Address - Street 2:
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850
Practice Address - Country:US
Practice Address - Phone:732-846-5852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00198400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ069905 DBDMedicare ID - Type Unspecified