Provider Demographics
NPI:1689828220
Name:COSTA, DOREEN M (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DOREEN
Middle Name:M
Last Name:COSTA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:DOREEN
Other - Middle Name:M
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:515 MOE RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3821
Mailing Address - Country:US
Mailing Address - Phone:518-280-4294
Mailing Address - Fax:518-280-4297
Practice Address - Street 1:515 MOE RD
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3821
Practice Address - Country:US
Practice Address - Phone:518-280-4294
Practice Address - Fax:518-280-4297
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007920-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist