Healthcare Provider Details

I. General information

NPI: 1396313896
Provider Name (Legal Business Name): KRISTEN DACOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2021
Last Update Date: 06/12/2021
Certification Date: 06/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 N PARK AVE
SHREWSBURY NJ
07702-4413
US

IV. Provider business mailing address

152 KINGS HWY
MIDDLETOWN NJ
07748-2023
US

V. Phone/Fax

Practice location:
  • Phone: 917-406-0478
  • Fax:
Mailing address:
  • Phone: 173-269-3129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT40QA00773200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: