Healthcare Provider Details

I. General information

NPI: 1154919496
Provider Name (Legal Business Name): COSTA THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 PAWTUCKET AVE STE 3
RUMFORD RI
02916-1431
US

IV. Provider business mailing address

PO BOX 41335
PROVIDENCE RI
02940-1335
US

V. Phone/Fax

Practice location:
  • Phone: 401-400-2023
  • Fax:
Mailing address:
  • Phone: 401-400-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CRISTINA M COSTA
Title or Position: SOCIAL WORKER
Credential: LICSW
Phone: 401-400-2023