Provider Demographics
NPI:1003568007
Name:COSTIN, CHERYL LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:COSTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 S MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5464
Mailing Address - Country:US
Mailing Address - Phone:301-607-9096
Mailing Address - Fax:301-829-1320
Practice Address - Street 1:1311 S MAIN ST STE 301
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5464
Practice Address - Country:US
Practice Address - Phone:301-607-9096
Practice Address - Fax:301-829-1320
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2559225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant