Provider Demographics
NPI:1588822308
Name:STATEN, COSTANCE YVETTE (DIRECTOR)
Entity Type:Individual
Prefix:MS
First Name:COSTANCE
Middle Name:YVETTE
Last Name:STATEN
Suffix:
Gender:F
Credentials:DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 GULF SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1535
Mailing Address - Country:US
Mailing Address - Phone:210-707-7784
Mailing Address - Fax:
Practice Address - Street 1:7000 GULFSHORE
Practice Address - Street 2:
Practice Address - City:SAN ANTONO
Practice Address - State:TX
Practice Address - Zip Code:78244
Practice Address - Country:US
Practice Address - Phone:210-707-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121763310400000X, 3104A0625X
TX217633104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX51430089Medicaid