Healthcare Provider Details

I. General information

NPI: 1962461608
Provider Name (Legal Business Name): THERESA DIANE ACOSTA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 10TH AVE ATHLETIC DEPT.
NEW YORK NY
10019-1069
US

IV. Provider business mailing address

753 E 5TH ST APT 3A
NEW YORK NY
10009-1274
US

V. Phone/Fax

Practice location:
  • Phone: 212-237-8324
  • Fax:
Mailing address:
  • Phone: 817-403-5140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number001384
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001384
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: