Provider Demographics
NPI:1689173841
Name:COSTAS, ANGELICA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIE
Last Name:COSTAS
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 1:75 GROTON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:AYER
Mailing Address - State:MA
Mailing Address - Zip Code:01432-1041
Mailing Address - Country:US
Mailing Address - Phone:978-751-1922
Mailing Address - Fax:
Practice Address - Street 1:75 GROTON SCHOOL RD APT G1
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1032
Practice Address - Country:US
Practice Address - Phone:978-751-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician