Provider Demographics
NPI:1851510812
Name:DACOSTA, ANTONIO (LCSW)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:DACOSTA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 N 16TH ST
Mailing Address - Street 2:SUITE #E-110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5121
Mailing Address - Country:US
Mailing Address - Phone:602-264-2770
Mailing Address - Fax:866-534-1701
Practice Address - Street 1:4620 N 16TH ST
Practice Address - Street 2:SUITE #E-110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5121
Practice Address - Country:US
Practice Address - Phone:602-264-2770
Practice Address - Fax:866-534-1701
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSW01941104100000X
AZLCSW-01941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ721002Medicaid
AZ72250Medicare PIN