Provider Demographics
NPI:1932501715
Name:COSTA, DONNA SUE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:SUE
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:SUE
Other - Last Name:GLISSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTA
Mailing Address - Street 1:550 W FRONTAGE RD STE 2415
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1212
Mailing Address - Country:US
Mailing Address - Phone:877-787-3422
Mailing Address - Fax:
Practice Address - Street 1:550 W FRONTAGE RD STE 2415
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1212
Practice Address - Country:US
Practice Address - Phone:877-787-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.000851225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant