=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093310898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIE M COSTA LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 12/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 E MAIN RD
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02842-4988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-608-3322
-----------------------------------------------------
Fax | 401-608-3323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 E MAIN RD
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02842-4988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-608-3322
-----------------------------------------------------
Fax | 401-608-3323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CSW02494
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------