Provider Demographics
NPI:1477271005
Name:COSTANZA, EMILY G (RBT)
Entity type:Individual
Prefix:MS
First Name:EMILY
Middle Name:G
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 COLONIAL BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1062
Mailing Address - Country:US
Mailing Address - Phone:239-351-3715
Mailing Address - Fax:239-310-2046
Practice Address - Street 1:3880 COLONIAL BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1062
Practice Address - Country:US
Practice Address - Phone:239-351-3715
Practice Address - Fax:239-310-2046
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty