Provider Demographics
NPI:1790451268
Name:ACOSTA, IVANNA SAMANTHA (MS)
Entity Type:Individual
Prefix:
First Name:IVANNA
Middle Name:SAMANTHA
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W 190TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4925
Mailing Address - Country:US
Mailing Address - Phone:310-819-4523
Mailing Address - Fax:877-394-6799
Practice Address - Street 1:1515 W 190TH ST STE 300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4925
Practice Address - Country:US
Practice Address - Phone:310-819-4523
Practice Address - Fax:877-394-6799
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst