Provider Demographics
NPI:1295138766
Name:COSTA, CRISTINA M (LICSW)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:M
Last Name:COSTA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CRISTINA
Other - Middle Name:M
Other - Last Name:COSTA-RADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 41335
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-1335
Mailing Address - Country:US
Mailing Address - Phone:401-952-3627
Mailing Address - Fax:
Practice Address - Street 1:1240 PAWTUCKET AVE STE 3
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:RI
Practice Address - Zip Code:02916-1431
Practice Address - Country:US
Practice Address - Phone:401-400-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW017571041C0700X
MA1206681041C0700X
RI704121041S0200X
MA2200411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1306952312Medicaid
RI1972662104Medicaid
RI1306952312Medicaid
RI1306952312Medicare UPIN
RI1972662104Medicare UPIN
RI1306952312Medicare NSC
RI1972662104Medicaid
RI1306952312Medicare Oscar/Certification
RI1972662104Medicare PIN
RI1306952312Medicare PIN