MEDICARE: MRS. ALICIA JANETTE KOSTOV 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	1041C0700X	Clinical Social Worker	113613	MA
2	1041C0700X	Clinical Social Worker	51367	TX
3	1041C0700X	Clinical Social Worker	LCSW-15849	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0051YP	OTHER	TX	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649283532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICIA JANETTE KOSTOV LCSW

Provider Business Mailing Address
First Line	:	1400 E SOUTHERN AVE
Second Line	:	SUITE 735
City	:	TEMPE
State	:	AZ
Zip	:	85282-5691
Country	:	US
Telephone Number	:	480-804-0326
Fax Number	:	480-804-0083

Provider Business Practice Location Address
First Line	:	2120 S MCCLINTOCK DR
Second Line	:	SUITE 105
City	:	TEMPE
State	:	AZ
Zip	:	85282-2692
Country	:	US
Telephone Number	:	480-804-0326
Fax Number	:	480-804-0083

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	04/23/2017

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Directions to “ MRS. ALICIA JANETTE KOSTOV LCSW” Practice Location

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