Provider Demographics
NPI:1720323702
Name:COSTA, SOFIA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:SOFIA
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 14TH ST
Mailing Address - Street 2:UNIT #3
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-3186
Mailing Address - Country:US
Mailing Address - Phone:956-357-6774
Mailing Address - Fax:
Practice Address - Street 1:900 WILSHIRE BLVD
Practice Address - Street 2:SUIT #318
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1872
Practice Address - Country:US
Practice Address - Phone:347-451-3626
Practice Address - Fax:424-272-9772
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA396642251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39664OtherSTATE LICENSE