Provider Demographics
NPI:1154669034
Name:COSTA, SHAUNTELE
Entity Type:Individual
Prefix:
First Name:SHAUNTELE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 DANVILLE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GREAT MEADOWS
Mailing Address - State:NJ
Mailing Address - Zip Code:07838-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 OXFORD RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NJ
Practice Address - Zip Code:07863-3224
Practice Address - Country:US
Practice Address - Phone:908-475-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01312600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist