MEDICARE: KAITLYN JORDANA COSTAS RCSWI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW25685	FL

General Provider Information

NPI Number	:	1114661626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN JORDANA COSTAS RCSWI

Provider Business Mailing Address
First Line	:	956 PONDEROSA PINE CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-3283
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	956 PONDEROSA PINE CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-3283
Country	:	US
Telephone Number	:	407-473-9113
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2022
Last Update Date	:	01/26/2026

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