Healthcare Provider Details

I. General information

NPI: 1114880010
Provider Name (Legal Business Name): ANGEL ACOSTA MHC-LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4902 QUEENS BLVD STE 2
WOODSIDE NY
11377-4445
US

IV. Provider business mailing address

4902 QUEENS BLVD STE 2
WOODSIDE NY
11377-4445
US

V. Phone/Fax

Practice location:
  • Phone: 929-296-6790
  • Fax:
Mailing address:
  • Phone: 929-296-6790
  • 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: