Healthcare Provider Details

I. General information

NPI: 1881144178
Provider Name (Legal Business Name): COSTA CLINICAL PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SPRUCE ST. # 7666
BROOKINGS OR
97415
US

IV. Provider business mailing address

625 SPRUCE ST. P.O. BOX 7666
BROOKINGS OR
97415
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-0700
  • Fax: 541-412-0711
Mailing address:
  • Phone: 541-412-0700
  • Fax: 541-412-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2356
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6298
License Number StateOR

VIII. Authorized Official

Name: DR. TERESA IONE COSTA
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 541-412-0700