Healthcare Provider Details

I. General information

NPI: 1578672242
Provider Name (Legal Business Name): JOSEPH P COSTANZO EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 NORTH ROAD
HAMPDEN MA
01036
US

IV. Provider business mailing address

425 NORTH ROAD
HAMPDEN MA
01036
US

V. Phone/Fax

Practice location:
  • Phone: 413-566-8503
  • Fax: 413-566-5185
Mailing address:
  • Phone: 413-566-8503
  • Fax: 413-566-5185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4729
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: