Provider Demographics
NPI:1821749409
Name:COSTA, CONNOR MICHAEL
Entity Type:Individual
Prefix:MR
First Name:CONNOR
Middle Name:MICHAEL
Last Name:COSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CONNOR
Other - Middle Name:MICHAEL
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 399318
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-9318
Mailing Address - Country:US
Mailing Address - Phone:866-523-4268
Mailing Address - Fax:
Practice Address - Street 1:5501 ANTIQUE ROSE WAY
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367-9505
Practice Address - Country:US
Practice Address - Phone:866-523-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician