Healthcare Provider Details

I. General information

NPI: 1689189458
Provider Name (Legal Business Name): ELEONORA ROSE COSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLIE MORTILLARO

II. Dates (important events)

Enumeration Date: 12/02/2017
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date: 02/07/2026
Reactivation Date: 02/18/2026

III. Provider practice location address

3 LOWE DR
GLOUCESTER MA
01930-5236
US

IV. Provider business mailing address

2 CARRIE LN
GLOUCESTER MA
01930-2328
US

V. Phone/Fax

Practice location:
  • Phone: 978-979-8104
  • Fax:
Mailing address:
  • Phone: 978-979-8104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10005524
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: