Provider Demographics
NPI:1841776184
Name:DA COSTA, SUSSANNIE LUCYNDA (MS, CRC,PSYD (ABD))
Entity Type:Individual
Prefix:
First Name:SUSSANNIE
Middle Name:LUCYNDA
Last Name:DA COSTA
Suffix:
Gender:F
Credentials:MS, CRC,PSYD (ABD)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1216
Mailing Address - Country:US
Mailing Address - Phone:208-717-1782
Mailing Address - Fax:
Practice Address - Street 1:1525 MAIN AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1216
Practice Address - Country:US
Practice Address - Phone:208-717-1782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Single Specialty