Provider Demographics
NPI:1437747540
Name:DE COSTA, TINALEE PUAWEHIWA (LPC)
Entity Type:Individual
Prefix:
First Name:TINALEE
Middle Name:PUAWEHIWA
Last Name:DE COSTA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76503-1108
Mailing Address - Country:US
Mailing Address - Phone:254-773-4022
Mailing Address - Fax:254-773-0919
Practice Address - Street 1:3816 CLEAR CREEK RD STE C301
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4107
Practice Address - Country:US
Practice Address - Phone:254-773-4022
Practice Address - Fax:254-773-0919
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX77917OtherSTATE OF TEXAS