Provider Demographics
NPI:1457540437
Name:BEVERLY A. COSTINEW PHD P.C.
Entity Type:Organization
Organization Name:BEVERLY A. COSTINEW PHD P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COSTINEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-923-8402
Mailing Address - Street 1:38345 W 10 MILE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2867
Mailing Address - Country:US
Mailing Address - Phone:810-923-8402
Mailing Address - Fax:810-355-1337
Practice Address - Street 1:38345 W 10 MILE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2867
Practice Address - Country:US
Practice Address - Phone:810-923-8402
Practice Address - Fax:810-355-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620F34792OtherBLUE CROSS BLUE SHIELD
MI620F34792OtherBLUE CROSS BLUE SHIELD