Provider Demographics
NPI:1558610972
Name:COSTANZA, ELIZABETH J (M, ED, CAGS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:M, ED, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-2768
Mailing Address - Country:US
Mailing Address - Phone:617-877-2265
Mailing Address - Fax:781-826-0054
Practice Address - Street 1:290 SPRING ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2768
Practice Address - Country:US
Practice Address - Phone:617-877-2265
Practice Address - Fax:781-826-0054
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool