Provider Demographics
NPI:1114764149
Name:FUSCO, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:FUSCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ANSBACHERSTR. 51
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:GERMANY
Mailing Address - Zip Code:10777
Mailing Address - Country:DE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ANSBACHERSTR. 51
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:GERMANY
Practice Address - Zip Code:10777
Practice Address - Country:DE
Practice Address - Phone:860-888-4778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54889289103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool