=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548825854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLINA COSTANZO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2019
-----------------------------------------------------
Last Update Date | 09/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 W HAWTHORNE AVE FL 2
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-456-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 TULIP AVE REAR
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-3756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-456-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 095221
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------