Provider Demographics
NPI:1073893509
Name:COSTA, JEFFREY A (PTA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:COSTA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2929
Mailing Address - Country:US
Mailing Address - Phone:203-455-7312
Mailing Address - Fax:
Practice Address - Street 1:39 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2929
Practice Address - Country:US
Practice Address - Phone:203-455-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT891225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant