Provider Demographics
NPI:1720141195
Name:ACOSTA, MARIA SUSANA (LPC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:SUSANA
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23071
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79923-0071
Mailing Address - Country:US
Mailing Address - Phone:915-407-1323
Mailing Address - Fax:915-778-4244
Practice Address - Street 1:1790 N LEE TREVINO DR
Practice Address - Street 2:SUITE 601A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4545
Practice Address - Country:US
Practice Address - Phone:915-407-1323
Practice Address - Fax:915-778-4244
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60613101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186865504Medicaid