Provider Demographics
NPI:1205401007
Name:COSTA, MICHAEL LEONARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEONARD
Last Name:COSTA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2572 43RD ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-2509
Mailing Address - Country:US
Mailing Address - Phone:516-670-5325
Mailing Address - Fax:
Practice Address - Street 1:2572 43RD ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-2509
Practice Address - Country:US
Practice Address - Phone:516-670-5325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent