Provider Demographics
NPI:1912163528
Name:MANCUSO, LIAM K (PHD)
Entity type:Individual
Prefix:DR
First Name:LIAM
Middle Name:K
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 BYRON ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-4602
Mailing Address - Country:US
Mailing Address - Phone:832-954-5546
Mailing Address - Fax:
Practice Address - Street 1:845 S LILLIAN ST
Practice Address - Street 2:STE A
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-5166
Practice Address - Country:US
Practice Address - Phone:832-954-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-03
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33426103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling