Provider Demographics
NPI:1851429328
Name:COSTANZO, WANDA ROSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:ROSE
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:WANDZ
Other - Middle Name:
Other - Last Name:COSTANZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:49 GROVE STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-1232
Mailing Address - Country:US
Mailing Address - Phone:856-428-6640
Mailing Address - Fax:856-428-9185
Practice Address - Street 1:49 GROVE STREET
Practice Address - Street 2:SUITE C
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1232
Practice Address - Country:US
Practice Address - Phone:856-428-6640
Practice Address - Fax:856-428-9185
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00138100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0825470000OtherAMERI HEALTH
J0180078OtherTRICARE CHAMPUS
0825470000OtherAMERI HEALTH