Provider Demographics
NPI:1295156594
Name:COSTA, KELLY L (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:COSTA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:90 KELSEY AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1139
Mailing Address - Country:US
Mailing Address - Phone:631-697-3827
Mailing Address - Fax:
Practice Address - Street 1:762 DEER PARK RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6221
Practice Address - Country:US
Practice Address - Phone:631-254-0094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-04
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP91676225100000X
NY037470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist