Provider Demographics
NPI:1780046938
Name:ACOSTA, GRETEL
Entity Type:Individual
Prefix:
First Name:GRETEL
Middle Name:
Last Name:ACOSTA
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 1:2051 HOMER AVE
Mailing Address - Street 2:PH
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2001
Mailing Address - Country:US
Mailing Address - Phone:917-455-4103
Mailing Address - Fax:
Practice Address - Street 1:2051 HOMER AVE
Practice Address - Street 2:PH
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2001
Practice Address - Country:US
Practice Address - Phone:917-455-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-27
Last Update Date:2016-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1286259103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool