Healthcare Provider Details

I. General information

NPI: 1124238167
Provider Name (Legal Business Name): GIOVANNI COSTALES LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22108 52ND AVE W
MOUNTLAKE TERRACE WA
98043-4007
US

IV. Provider business mailing address

22108 52ND AVE W
MOUNTLAKE TERRACE WA
98043-4007
US

V. Phone/Fax

Practice location:
  • Phone: 206-550-2205
  • Fax:
Mailing address:
  • Phone: 206-550-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00018033
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: