Provider Demographics
NPI:1114661626
Name:COSTAS, KAITLYN JORDANA (RCSWI)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:JORDANA
Last Name:COSTAS
Suffix:
Gender:F
Credentials:RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10483 RIVA RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-2874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10967 LAKE UNDERHILL RD STE 113
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4434
Practice Address - Country:US
Practice Address - Phone:407-473-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW157791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical