MEDICARE: LAUREN COSTINE

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	103T00000X	Psychologist	PSY 22916	CA

General Provider Information

NPI Number	:	1225439268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN COSTINE

Provider Business Mailing Address
First Line	:	700 WESTMOUNT DR
Second Line	:	SUITE 107
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-5164
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 WESTMOUNT DR
Second Line	:	SUITE 107
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-5164
Country	:	US
Telephone Number	:	855-277-5363
Fax Number	:

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

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	09/09/2014

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Directions to “ LAUREN COSTINE ” Practice Location

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