Provider Demographics
NPI:1417677477
Name:COSTAGLIOLA, VINCENT (CTRS)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:COSTAGLIOLA
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4310
Mailing Address - Country:US
Mailing Address - Phone:516-754-2367
Mailing Address - Fax:
Practice Address - Street 1:2724 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-4310
Practice Address - Country:US
Practice Address - Phone:516-754-2367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68106225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist