Provider Demographics
NPI:1003961921
Name:COSTA, EDWARD JOHN (LICSW)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JOHN
Last Name:COSTA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-2625
Mailing Address - Country:US
Mailing Address - Phone:508-672-4237
Mailing Address - Fax:
Practice Address - Street 1:879 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2625
Practice Address - Country:US
Practice Address - Phone:508-672-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10269461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012840Medicare UPIN
MAP30039Medicare ID - Type UnspecifiedMEDICARE
RI2804-001Medicare UPIN
CT7354301Medicare UPIN
MAP07682Medicare UPIN
RICP00406723Medicare UPIN