MEDICARE: KIRSTEN ELISE COSTA

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	101YP2500X	Professional Counselor	5871087	ID
2	101YM0800X	Mental Health Counselor	5871087	ID

General Provider Information

NPI Number	:	1679439830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN ELISE COSTA

Provider Business Mailing Address
First Line	:	PO BOX 312
Second Line	:
City	:	LUCILE
State	:	ID
Zip	:	83542-0312
Country	:	US
Telephone Number	:	208-500-2066
Fax Number	:

Provider Business Practice Location Address
First Line	:	318 E MAIN ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-2238
Country	:	US
Telephone Number	:	208-500-2066
Fax Number	:

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

Provider Enumeration Date	:	01/01/2026
Last Update Date	:	01/01/2026

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Directions to “ KIRSTEN ELISE COSTA ” Practice Location

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