Provider Demographics
NPI:1619902723
Name:COSTINE, ELIZABETH MARY (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:COSTINE
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 DANSK CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-3195
Mailing Address - Country:US
Mailing Address - Phone:919-523-2110
Mailing Address - Fax:919-465-3462
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2472
Practice Address - Country:US
Practice Address - Phone:919-523-2110
Practice Address - Fax:919-465-3462
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3495101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102773Medicaid