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General NPI Number Information
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NPI Number | 1790140341
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Entity Type | Individual
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Provider Name | IAN DACOSTA
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Gender | Male
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Dates
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Enumeration Date | 12/28/2015
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Last Update Date | 12/28/2015
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Provider Practice Location Address
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Address Line | 3050 WHITE PLAINS ROAD
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City | BRONX
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State | NY
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Zip | 10469
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Country | US
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Telephone | 929-348-4486
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Fax | 718-944-7090
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Provider Business Mailing Address
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Address Line | 1834 DOGWOOD DRIVE
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City | YORKTOWN HEIGHTS
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State | NY
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Zip | 10598
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Country | US
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Telephone | 917-916-7368
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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