Provider Demographics
NPI:1568624666
Name:COSTA, ETHEL C (PT)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:C
Last Name:COSTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 GINKGO CT
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-3921
Mailing Address - Country:US
Mailing Address - Phone:717-261-4174
Mailing Address - Fax:717-261-1092
Practice Address - Street 1:5500 BROOKTREE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9260
Practice Address - Country:US
Practice Address - Phone:180-067-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012024L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist