Healthcare Provider Details

I. General information

NPI: 1902108681
Provider Name (Legal Business Name): STEPHANIE COSTANZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE NEUBAUER

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 COVIL AVE STE 102
WILMINGTON NC
28403-2683
US

IV. Provider business mailing address

2165 EMERALD AVE
CASTLE HAYNE NC
28429-5691
US

V. Phone/Fax

Practice location:
  • Phone: 910-810-0665
  • Fax:
Mailing address:
  • Phone: 910-810-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-46512
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: