=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649048117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. RICKY LAVORN COSTON JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2023
-----------------------------------------------------
Last Update Date | 12/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11164 WILLOW DR APT T
-----------------------------------------------------
City | BEALETON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22712-9210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-746-0113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11164 WILLOW DR APT T
-----------------------------------------------------
City | BEALETON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22712-9210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 0704016397
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number | PPS-0605419
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------