Provider Demographics
NPI:1639852619
Name:DICOSTANZO, LANA
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:DICOSTANZO
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 1:503 S YATES ST
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-3695
Mailing Address - Country:US
Mailing Address - Phone:917-881-5108
Mailing Address - Fax:
Practice Address - Street 1:175 W FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4145
Practice Address - Country:US
Practice Address - Phone:704-865-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0193961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical