Provider Demographics
NPI:1396154621
Name:MANSUETO, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MANSUETO
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 1:140 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-2235
Mailing Address - Country:US
Mailing Address - Phone:844-365-7474
Mailing Address - Fax:844-365-7676
Practice Address - Street 1:140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071-2235
Practice Address - Country:US
Practice Address - Phone:844-365-7474
Practice Address - Fax:844-365-7676
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00492600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health