Provider Demographics
NPI:1629843867
Name:COSTA, SOPHIA BELCHIOR
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:BELCHIOR
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-1031
Mailing Address - Country:US
Mailing Address - Phone:774-406-9055
Mailing Address - Fax:
Practice Address - Street 1:1260 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1305
Practice Address - Country:US
Practice Address - Phone:603-314-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program