Provider Demographics
NPI:1124379961
Name:COSTA, MELYNDA RAE
Entity Type:Individual
Prefix:MRS
First Name:MELYNDA
Middle Name:RAE
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MELYNDA
Other - Middle Name:RAE
Other - Last Name:BLAYLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26448 S EDINBURG CT
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-5598
Mailing Address - Country:US
Mailing Address - Phone:815-521-0372
Mailing Address - Fax:815-521-0372
Practice Address - Street 1:26448 S EDINBURG CT
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-5598
Practice Address - Country:US
Practice Address - Phone:815-521-0372
Practice Address - Fax:815-521-0372
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist