Provider Demographics
NPI:1114510161
Name:ABERCROMBIE, COSTROMAS
Entity Type:Individual
Prefix:
First Name:COSTROMAS
Middle Name:
Last Name:ABERCROMBIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-5006
Mailing Address - Country:US
Mailing Address - Phone:323-242-5000
Mailing Address - Fax:310-945-3356
Practice Address - Street 1:11601 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-5006
Practice Address - Country:US
Practice Address - Phone:323-242-5000
Practice Address - Fax:310-945-3356
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA101075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner