Provider Demographics
NPI:1184194250
Name:COSTILLA, PATRICIA L (LPCA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:L
Last Name:COSTILLA
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3106
Mailing Address - Country:US
Mailing Address - Phone:803-743-6128
Mailing Address - Fax:
Practice Address - Street 1:9217 UNIVERSITY BLVD STE C1A
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9147
Practice Address - Country:US
Practice Address - Phone:843-619-7989
Practice Address - Fax:888-855-8030
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6630101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health