Provider Demographics
NPI:1134263247
Name:COSTAS, MYRIANLEE I (PHD)
Entity type:Individual
Prefix:
First Name:MYRIANLEE
Middle Name:
Last Name:COSTAS
Suffix:I
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COND. AVENTURA APT. 6609
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-599-6572
Mailing Address - Fax:
Practice Address - Street 1:7 CALLE GUARIONEX
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-4431
Practice Address - Country:US
Practice Address - Phone:787-767-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2391103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical