Healthcare Provider Details

I. General information

NPI: 1053243279
Provider Name (Legal Business Name): JOHN COSTANZO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

650 S GRANDRIDGE AVE
MONTEREY PARK CA
91754-3921
US

IV. Provider business mailing address

2479 VISTA LAGUNA TER
PASADENA CA
91103-1022
US

V. Phone/Fax

Practice location:
  • Phone: 626-570-6249
  • Fax:
Mailing address:
  • Phone: 323-804-1269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number240204609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: