Healthcare Provider Details

I. General information

NPI: 1922879741
Provider Name (Legal Business Name): ANGELA GABRIELLE COSTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 E BROADWAY
LONG BEACH CA
90803-6035
US

IV. Provider business mailing address

2512 ARTESIA BLVD STE 305F
REDONDO BEACH CA
90278-3269
US

V. Phone/Fax

Practice location:
  • Phone: 888-242-2522
  • Fax:
Mailing address:
  • Phone: 323-844-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT28659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: