Provider Demographics
NPI:1487863916
Name:COSTA, MIRIAM (LPTA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 BRIARGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-5841
Mailing Address - Country:US
Mailing Address - Phone:863-221-8858
Mailing Address - Fax:
Practice Address - Street 1:735 BRIARGROVE AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-5841
Practice Address - Country:US
Practice Address - Phone:863-221-8858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA1853225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant