Healthcare Provider Details

I. General information

NPI: 1245702562
Provider Name (Legal Business Name): NOELLE MARIE COSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCENIC DR
MODESTO CA
95350-6131
US

IV. Provider business mailing address

2934 N FRESNO ST
FRESNO CA
93703-1123
US

V. Phone/Fax

Practice location:
  • Phone: 209-552-2774
  • Fax:
Mailing address:
  • Phone: 559-558-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number114790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: