MEDICARE: MRS. KIMBERLEY SAMANTHA COSTA CCC-SLP

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	235Z00000X	Speech-Language Pathologist	024549-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376912964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLEY SAMANTHA COSTA CCC-SLP

Provider Business Mailing Address
First Line	:	312 E 90TH ST
Second Line	:	APT 3B
City	:	NEW YORK
State	:	NY
Zip	:	10128-5124
Country	:	US
Telephone Number	:	740-856-6048
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 E 90TH ST
Second Line	:	APT 3B
City	:	NEW YORK
State	:	NY
Zip	:	10128-5124
Country	:	US
Telephone Number	:	740-856-6048
Fax Number	:

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

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	08/17/2016

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Directions to “ MRS. KIMBERLEY SAMANTHA COSTA CCC-SLP” Practice Location

Language	Start Address	Practice Location

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