1487274858 NPI number — MONICA WREN BABCOCK MANCUSO MPH, RD

Table of content: MONICA WREN BABCOCK MANCUSO MPH, RD (NPI 1487274858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487274858 NPI number — MONICA WREN BABCOCK MANCUSO MPH, RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCUSO
Provider First Name:
MONICA
Provider Middle Name:
WREN BABCOCK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPH, RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BABCOCK
Provider Other First Name:
MONICA
Provider Other Middle Name:
WREN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPH, RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487274858
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30680 GLENMUER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-860-4853
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 KIRTS BLVD APT 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-4342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-860-4853
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  86068236 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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