Provider Demographics
NPI:1407626146
Name:COSTA, CHRISTINA JENNIE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:JENNIE
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 1:5 CENTRAL ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-2001
Mailing Address - Country:US
Mailing Address - Phone:508-740-2068
Mailing Address - Fax:
Practice Address - Street 1:108 GROVE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2651
Practice Address - Country:US
Practice Address - Phone:508-859-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000227784104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker