Provider Demographics
NPI:1629535729
Name:COSTA, STEPHANIE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:840 WINTER ST
Mailing Address - Street 2:ATTN: PRO SPORTS THERAPY
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1433
Mailing Address - Country:US
Mailing Address - Phone:781-487-9944
Mailing Address - Fax:781-487-9944
Practice Address - Street 1:840 WINTER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1433
Practice Address - Country:US
Practice Address - Phone:781-487-9944
Practice Address - Fax:781-487-9944
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8009225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant