Healthcare Provider Details

I. General information

NPI: 1003124983
Provider Name (Legal Business Name): WILLIAM COSTA MHRT-CSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 STEVES LN
MARSHFIELD ME
04654-5045
US

IV. Provider business mailing address

180 ACADEMY ST STE 3
PRESQUE ISLE ME
04769-3183
US

V. Phone/Fax

Practice location:
  • Phone: 207-255-0995
  • Fax: 207-255-8748
Mailing address:
  • Phone: 207-554-2352
  • Fax: 207-554-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: