Provider Demographics
NPI:1477303485
Name:COSTA, SHIVONNE
Entity Type:Individual
Prefix:
First Name:SHIVONNE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHIVONNE
Other - Middle Name:
Other - Last Name:KEISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 LIGONIER ST
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-2912
Mailing Address - Country:US
Mailing Address - Phone:724-804-7297
Mailing Address - Fax:
Practice Address - Street 1:1501 LIGONIER ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-2912
Practice Address - Country:US
Practice Address - Phone:724-804-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health