Provider Demographics
NPI:1134662513
Name:DA COSTA, KATHLEEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DA COSTA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7224 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1533
Mailing Address - Country:US
Mailing Address - Phone:718-533-6754
Mailing Address - Fax:718-533-6794
Practice Address - Street 1:7224 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1533
Practice Address - Country:US
Practice Address - Phone:718-533-6754
Practice Address - Fax:718-533-6794
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist