Provider Demographics
NPI:1629675194
Name:DE COSTA, COLOMBAGE ASHA (LMHC, EDM)
Entity Type:Individual
Prefix:
First Name:COLOMBAGE
Middle Name:ASHA
Last Name:DE COSTA
Suffix:
Gender:F
Credentials:LMHC, EDM
Other - Prefix:
Other - First Name:ASHA
Other - Middle Name:
Other - Last Name:DE COSTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC, EDM
Mailing Address - Street 1:106 FORT WASHINGTON AVE APT 3K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4723
Mailing Address - Country:US
Mailing Address - Phone:917-406-4015
Mailing Address - Fax:
Practice Address - Street 1:106 FORT WASHINGTON AVE APT 3K
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-4723
Practice Address - Country:US
Practice Address - Phone:917-406-4015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0086741-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health