Provider Demographics
NPI:1497149553
Name:ACOSTA, JOHN ALEX (LADC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALEX
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 EAST 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106
Mailing Address - Country:US
Mailing Address - Phone:651-379-4200
Mailing Address - Fax:651-292-0347
Practice Address - Street 1:797 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-5014
Practice Address - Country:US
Practice Address - Phone:651-379-4200
Practice Address - Fax:651-292-0347
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304108101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)