Provider Demographics
NPI:1134597263
Name:COSTAGLIOLA, AMANDA (SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:COSTAGLIOLA
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 WINDBEAM RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457-1618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 WINDBEAM RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457-1618
Practice Address - Country:US
Practice Address - Phone:973-903-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-06
Last Update Date:2015-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00758900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist