Provider Demographics
NPI:1376912964
Name:COSTA, KIMBERLEY SAMANTHA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:SAMANTHA
Last Name:COSTA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:KIMBERLEY
Other - Middle Name:SAMANTHA
Other - Last Name:GHANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:312 E 90TH ST
Mailing Address - Street 2:APT 3B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5124
Mailing Address - Country:US
Mailing Address - Phone:740-856-6048
Mailing Address - Fax:
Practice Address - Street 1:312 E 90TH ST
Practice Address - Street 2:APT 3B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5124
Practice Address - Country:US
Practice Address - Phone:740-856-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024549-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04285489Medicaid