Provider Demographics
NPI:1962461608
Name:ACOSTA, THERESA DIANE (ATC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:DIANE
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 E 5TH ST
Mailing Address - Street 2:APT 3A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-1274
Mailing Address - Country:US
Mailing Address - Phone:817-403-5140
Mailing Address - Fax:
Practice Address - Street 1:899 10TH AVE
Practice Address - Street 2:ATHLETIC DEPT.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1069
Practice Address - Country:US
Practice Address - Phone:212-237-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001384390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program