Provider Demographics
NPI:1497959993
Name:COSTA, JOHN (LSW LADC I CADAC II)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:LSW LADC I CADAC II
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 79354
Mailing Address - Street 2:
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-0984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:150-823-5010
Practice Address - Fax:508-235-5053
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA300569101Y00000X
MA2107101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor