Provider Demographics
NPI:1558631283
Name:COSTON, TIMOTHY OLIVER JR
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:OLIVER
Last Name:COSTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80595 KEY LARGO DR
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-8337
Mailing Address - Country:US
Mailing Address - Phone:760-219-8555
Mailing Address - Fax:
Practice Address - Street 1:81709 DR CARREON BLVD STE D1
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5578
Practice Address - Country:US
Practice Address - Phone:760-347-2398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist