Healthcare Provider Details

I. General information

NPI: 1962843128
Provider Name (Legal Business Name): VICKI CENTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKI MAE COSTA LCSW

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10665 YEAGER AVE
HASTINGS FL
32145-9412
US

IV. Provider business mailing address

10665 YEAGER AVE
HASTINGS FL
32145-9412
US

V. Phone/Fax

Practice location:
  • Phone: 443-553-0335
  • Fax:
Mailing address:
  • Phone: 443-553-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberQ1-0000824
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: