MEDICARE: COURTNEY COSTA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1255854550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY COSTA LCSW

Provider Business Mailing Address
First Line	:	3339 STOCKTIE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-6476
Country	:	US
Telephone Number	:	919-866-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	3117 WHITING AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1648
Country	:	US
Telephone Number	:	919-866-2273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2017
Last Update Date	:	09/14/2022

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