Provider Demographics
NPI:1720111941
Name:COSTNER, CARY
Entity Type:Individual
Prefix:MR
First Name:CARY
Middle Name:
Last Name:COSTNER
Suffix:
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 1:909 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-6416
Mailing Address - Country:US
Mailing Address - Phone:714-973-1558
Mailing Address - Fax:
Practice Address - Street 1:1900 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-1647
Practice Address - Country:US
Practice Address - Phone:714-399-3480
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 Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health