Healthcare Provider Details

I. General information

NPI: 1932079498
Provider Name (Legal Business Name): THOMAS J COSTIN OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11460 W WASHINGTON BLVD
LOS ANGELES CA
90066-6030
US

IV. Provider business mailing address

13700 MARINA POINTE DR UNIT 1012
MARINA DEL REY CA
90292-9265
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT28364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: