Provider Demographics
NPI:1063508893
Name:KOUSTAS, AFTHALIA (MSPT)
Entity Type:Individual
Prefix:
First Name:AFTHALIA
Middle Name:
Last Name:KOUSTAS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MEETINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6090
Mailing Address - Country:US
Mailing Address - Phone:603-644-8334
Mailing Address - Fax:603-644-8339
Practice Address - Street 1:207 MEETINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6090
Practice Address - Country:US
Practice Address - Phone:603-644-8334
Practice Address - Fax:603-644-8339
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2827225100000X
NHPT2827225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH08Y004684NH02OtherBLUE CROSS BLUE SHIELD
NH30394080Medicaid
NHAA51080OtherHARVARD PILGRIM
NH9683166OtherCIGNA HEALTHCARE
NH08Y004684NH02OtherBLUE CROSS BLUE SHIELD