Provider Demographics
NPI:1477045979
Name:COSTA, AMANDA RAE (MSED MENTAL HEALTH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:COSTA
Suffix:
Gender:F
Credentials:MSED MENTAL HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2224
Mailing Address - Country:US
Mailing Address - Phone:786-553-0488
Mailing Address - Fax:
Practice Address - Street 1:2200 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2724
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health