Provider Demographics
NPI:1932461811
Name:KOSTULAS, BRENDA
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:KOSTULAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 CEDARWOOD HALL
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595
Mailing Address - Country:US
Mailing Address - Phone:914-419-5139
Mailing Address - Fax:914-493-8066
Practice Address - Street 1:3 GREENLAWN RD
Practice Address - Street 2:
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567-6751
Practice Address - Country:US
Practice Address - Phone:914-419-5139
Practice Address - Fax:914-493-8066
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator