Healthcare Provider Details

I. General information

NPI: 1992338677
Provider Name (Legal Business Name): ANA GEORGINA ACOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 NE KELLY AVE # 100C
GRESHAM OR
97030-5629
US

IV. Provider business mailing address

14213 SE CENTER ST
PORTLAND OR
97236-2741
US

V. Phone/Fax

Practice location:
  • Phone: 503-912-5502
  • Fax:
Mailing address:
  • Phone: 971-712-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: