Healthcare Provider Details

I. General information

NPI: 1568386399
Provider Name (Legal Business Name): STEPHANIE NICOLE COSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 AUSTIN ST
BRIDGEWATER MA
02324-1314
US

IV. Provider business mailing address

27 AUSTIN ST
BRIDGEWATER MA
02324-1314
US

V. Phone/Fax

Practice location:
  • Phone: 774-240-1691
  • Fax:
Mailing address:
  • Phone: 774-240-1691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberSA8120174
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: