Provider Demographics
NPI:1407159700
Name:COSTA, STACY CAMILLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:CAMILLE
Last Name:COSTA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 CARPENTER ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-2515
Mailing Address - Country:US
Mailing Address - Phone:215-687-1908
Mailing Address - Fax:
Practice Address - Street 1:2121 CARPENTER ST
Practice Address - Street 2:UNIT 2
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-2515
Practice Address - Country:US
Practice Address - Phone:215-687-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009892225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist