Healthcare Provider Details

I. General information

NPI: 1649048117
Provider Name (Legal Business Name): MR. RICKY LAVORN COSTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11164 WILLOW DR APT T
BEALETON VA
22712-9210
US

IV. Provider business mailing address

11164 WILLOW DR APT T
BEALETON VA
22712-9210
US

V. Phone/Fax

Practice location:
  • Phone: 757-746-0113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0704016397
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberPPS-0605419
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: