MEDICARE: DANIELLE COSTANZO MFT

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1942991708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE COSTANZO MFT

Provider Business Mailing Address
First Line	:	2165 E LETTERLY ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2136
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 RITTENHOUSE SQ
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-5837
Country	:	US
Telephone Number	:	267-606-0485
Fax Number	:

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

Provider Enumeration Date	:	05/15/2023
Last Update Date	:	05/15/2023

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