Healthcare Provider Details

I. General information

NPI: 1891063897
Provider Name (Legal Business Name): BESSIE NAOMI COSTANZA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 HAYNES ST STE 3
CLARKSVILLE TN
37043
US

IV. Provider business mailing address

5451 HIGHWAY 49 W
VANLEER TN
37181-5036
US

V. Phone/Fax

Practice location:
  • Phone: 931-980-1584
  • Fax:
Mailing address:
  • Phone: 931-980-1584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5175
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: