Provider Demographics
NPI:1700910890
Name:COSTALES, PATRICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:COSTALES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:COSTALES FLEMING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:2406A GATES AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2116
Mailing Address - Country:US
Mailing Address - Phone:310-371-3245
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:310-390-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS180821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical