Provider Demographics
NPI:1649457672
Name:COSTIN, AMANDA (PHD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:COSTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 CARDINAL WAY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-9201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 TRUMBULL RD
Practice Address - Street 2:#304
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3079
Practice Address - Country:US
Practice Address - Phone:413-397-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000006442101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health