Provider Demographics
NPI:1043380041
Name:ACOSTA, JUDITH (LISW LCSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:LISW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ROADRUNNER TRAIL
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043
Mailing Address - Country:US
Mailing Address - Phone:505-771-2282
Mailing Address - Fax:
Practice Address - Street 1:16 ROADRUNNER TRAIL
Practice Address - Street 2:
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043
Practice Address - Country:US
Practice Address - Phone:505-771-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI062921041C0700X
NY04213711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM160289OtherGHI
NY160289OtherVALUE OPTIONS