Provider Demographics
NPI:1649048117
Name:COSTON, RICKY LAVORN JR
Entity type:Individual
Prefix:MR
First Name:RICKY
Middle Name:LAVORN
Last Name:COSTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11164 WILLOW DR APT T
Mailing Address - Street 2:
Mailing Address - City:BEALETON
Mailing Address - State:VA
Mailing Address - Zip Code:22712-9210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11164 WILLOW DR APT T
Practice Address - Street 2:
Practice Address - City:BEALETON
Practice Address - State:VA
Practice Address - Zip Code:22712-9210
Practice Address - Country:US
Practice Address - Phone:757-746-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016397101Y00000X
VAPPS-0605419101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101Y00000XBehavioral Health & Social Service ProvidersCounselor