Provider Demographics
NPI:1639843246
Name:COSTA, ANTHONY J JR (PTA, PT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:COSTA
Suffix:JR
Gender:M
Credentials:PTA, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-1547
Mailing Address - Country:US
Mailing Address - Phone:330-533-1080
Mailing Address - Fax:
Practice Address - Street 1:567 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-1547
Practice Address - Country:US
Practice Address - Phone:330-533-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225200000X
OHPT020858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant