Provider Demographics
NPI:1447759014
Name:KOSTISHAK, ERIKA LOUANN
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:LOUANN
Last Name:KOSTISHAK
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 1:63 GLEN ECHO AVE
Mailing Address - Street 2:
Mailing Address - City:SWEDESBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-1241
Mailing Address - Country:US
Mailing Address - Phone:609-502-8350
Mailing Address - Fax:
Practice Address - Street 1:923 HADDONFIELD RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2752
Practice Address - Country:US
Practice Address - Phone:603-417-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NJ1-20-43455103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician