Provider Demographics
NPI:1265616718
Name:COSTA, ANA M (LICSW)
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:M
Last Name:COSTA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-1864
Mailing Address - Country:US
Mailing Address - Phone:781-864-7729
Mailing Address - Fax:
Practice Address - Street 1:416 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3842
Practice Address - Country:US
Practice Address - Phone:781-864-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1136161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical