Provider Demographics
NPI:1649283532
Name:KOSTOV, ALICIA JANETTE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:JANETTE
Last Name:KOSTOV
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:ALICIA
Other - Middle Name:JANETTE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1400 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 735
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5691
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:480-804-0083
Practice Address - Street 1:2120 S MCCLINTOCK DR
Practice Address - Street 2:SUITE 105
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2692
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-804-0083
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1136131041C0700X
TX513671041C0700X
AZLCSW-158491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162516Medicaid
TX0051YPOtherBLUE CROSS
TX613430Medicaid
AZZ191525Medicare PIN
TX613430Medicaid