Provider Demographics
NPI:1881144178
Name:COSTA CLINICAL PSYCHOLOGY, LLC
Entity type:Organization
Organization Name:COSTA CLINICAL PSYCHOLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:IONE
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:541-412-0700
Mailing Address - Street 1:625 SPRUCE ST.
Mailing Address - Street 2:P.O. BOX 7666
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415
Mailing Address - Country:US
Mailing Address - Phone:541-412-0700
Mailing Address - Fax:541-412-0711
Practice Address - Street 1:625 SPRUCE ST.
Practice Address - Street 2:# 7666
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-412-0700
Practice Address - Fax:541-412-0711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL62981041C0700X
OR2356103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500659667Medicaid
ORR16961OtherMEDICARE PTAN