Healthcare Provider Details

I. General information

NPI: 1760327563
Provider Name (Legal Business Name): AMBER KRISTEN COSTANZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10789 TERRA VISTA PKWY
RANCHO CUCAMONGA CA
91730-7324
US

IV. Provider business mailing address

9992 PALO ALTO ST
RANCHO CUCAMONGA CA
91730-1539
US

V. Phone/Fax

Practice location:
  • Phone: 909-980-1230
  • Fax:
Mailing address:
  • Phone: 909-518-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP27510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: