Provider Demographics
NPI:1659511285
Name:KOSTIN, TRICIA (LSW)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:KOSTIN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 MOUNTAIN AVE
Mailing Address - Street 2:PMB 365
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3231
Mailing Address - Country:US
Mailing Address - Phone:973-699-0029
Mailing Address - Fax:
Practice Address - Street 1:256 COLUMBIA TPKE
Practice Address - Street 2:SUITE 100N
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1209
Practice Address - Country:US
Practice Address - Phone:973-593-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05533500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker