=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194447193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COSTA COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2022
-----------------------------------------------------
Last Update Date | 09/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3117 WHITING AVE
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28205-1648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-866-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3339 STOCKTIE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-6476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | COURTNEY COSTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-866-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------