Healthcare Provider Details

I. General information

NPI: 1316977432
Provider Name (Legal Business Name): MRS. MICHAELLA D COSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHAELLA D MORAN

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NEWMAN AVE
RUMFORD RI
02916-1218
US

IV. Provider business mailing address

225 NEWMAN AVE
RUMFORD RI
02916-1218
US

V. Phone/Fax

Practice location:
  • Phone: 401-349-2911
  • Fax:
Mailing address:
  • Phone: 401-349-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01242
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: