Provider Demographics
NPI:1639947161
Name:COSTA, CHARLENE E (OTR/L)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:E
Last Name:COSTA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331
Mailing Address - Country:US
Mailing Address - Phone:978-906-1254
Mailing Address - Fax:
Practice Address - Street 1:2270 MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331
Practice Address - Country:US
Practice Address - Phone:978-906-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH-0T-5222225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation