Provider Demographics
NPI:1336354752
Name:COSTANZA, SCOTT MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:COSTANZA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 S JOG RD STE B8
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-1246
Mailing Address - Country:US
Mailing Address - Phone:561-279-9295
Mailing Address - Fax:
Practice Address - Street 1:1200 N FEDERAL HWY
Practice Address - Street 2:STE 200
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-2813
Practice Address - Country:US
Practice Address - Phone:561-279-9295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5739103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0421Medicare ID - Type UnspecifiedPSYCHOLOGIST