MEDICARE: DR. THERESA L. COSTALES M.D.

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	2084P0800X	Psychiatry Physician	280190-1	NY
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2084P0800X	Psychiatry Physician	57600	AZ

General Provider Information

NPI Number	:	1518200674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA L. COSTALES M.D.

Provider Business Mailing Address
First Line	:	2390 E CAMELBACK RD STE 400
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-3479
Country	:	US
Telephone Number	:	716-628-6338
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 S 7TH AVE STE 150
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-4075
Country	:	US
Telephone Number	:	716-628-6338
Fax Number	:

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

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	02/16/2022

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