Provider Demographics
NPI:1356625149
Name:COSTLEY, DAVIDE JEANETTE (MA, LPC)
Entity type:Individual
Prefix:
First Name:DAVIDE
Middle Name:JEANETTE
Last Name:COSTLEY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6374 F ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7084
Mailing Address - Country:US
Mailing Address - Phone:547-747-1235
Mailing Address - Fax:
Practice Address - Street 1:1345 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424
Practice Address - Country:US
Practice Address - Phone:541-942-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional