Provider Demographics
NPI:1518200674
Name:COSTALES, THERESA L (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
Last Name:COSTALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:MAURO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2390 E CAMELBACK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3479
Mailing Address - Country:US
Mailing Address - Phone:716-628-6338
Mailing Address - Fax:
Practice Address - Street 1:1201 S 7TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-4075
Practice Address - Country:US
Practice Address - Phone:716-628-6338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280190-12084P0800X
390200000X
AZ576002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program