Provider Demographics
NPI:1669976650
Name:KOSTOFF, PATRICIA E (MA)
Entity type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:E
Last Name:KOSTOFF
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 SUNSET PL STE C
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6544
Mailing Address - Country:US
Mailing Address - Phone:720-771-5800
Mailing Address - Fax:
Practice Address - Street 1:1823 SUNSET PL STE C
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6544
Practice Address - Country:US
Practice Address - Phone:720-771-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-44403103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO106S00000XMedicaid