Provider Demographics
NPI:1093083149
Name:COSTA, RAYMOND (LPC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 ROUTE 516
Mailing Address - Street 2:SUITE C AND D
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-7022
Mailing Address - Country:US
Mailing Address - Phone:732-679-4500
Mailing Address - Fax:732-679-4549
Practice Address - Street 1:4122 ROUTE 516
Practice Address - Street 2:SUITE C AND D
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-7022
Practice Address - Country:US
Practice Address - Phone:732-679-4500
Practice Address - Fax:732-679-4549
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00394900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional