Provider Demographics
NPI:1619513496
Name:COSTNER, ALICIA RENEE (BCABA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:RENEE
Last Name:COSTNER
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:MRS
Other - First Name:ALICIA
Other - Middle Name:RENEE
Other - Last Name:IDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13001 SEASCAPE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7113
Mailing Address - Country:US
Mailing Address - Phone:704-877-3191
Mailing Address - Fax:
Practice Address - Street 1:1698 HWY 160 W.
Practice Address - Street 2:STE. 240
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-2970
Practice Address - Country:US
Practice Address - Phone:704-654-8599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0-19-9516103K00000X
0-19-9516106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst