Provider Demographics
NPI:1598291858
Name:CONDOUS, KOSTA PAUL
Entity Type:Individual
Prefix:
First Name:KOSTA
Middle Name:PAUL
Last Name:CONDOUS
Suffix:
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:PO BOX 4489
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-4489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27405 PUERTA REAL
Practice Address - Street 2:SUITE 330
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6314
Practice Address - Country:US
Practice Address - Phone:949-478-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist