Healthcare Provider Details

I. General information

NPI: 1477384956
Provider Name (Legal Business Name): ELIAS PORTER COSTON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 ADAM CLAYTON POWELL JR BLVD FL 4
NEW YORK NY
10027-4941
US

IV. Provider business mailing address

339 E 12TH ST APT 2
NEW YORK NY
10003-7251
US

V. Phone/Fax

Practice location:
  • Phone: 212-553-6708
  • Fax:
Mailing address:
  • Phone: 646-206-6741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: