Healthcare Provider Details

I. General information

NPI: 1922045467
Provider Name (Legal Business Name): JILL SUSAN COSTA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5099A MERRICK RD
MASSAPEQUA PARK NY
11762-3727
US

IV. Provider business mailing address

3001 BELLMORE AVE
BELLMORE NY
11710-4328
US

V. Phone/Fax

Practice location:
  • Phone: 516-798-9605
  • Fax:
Mailing address:
  • Phone: 516-804-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number026314
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: