Provider Demographics
NPI:1881375681
Name:COSTANZO, MIKALA (LMHC)
Entity type:Individual
Prefix:
First Name:MIKALA
Middle Name:
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MIKALA
Other - Middle Name:
Other - Last Name:KORBEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:107 ST ANDRE DR
Mailing Address - Street 2:
Mailing Address - City:UXBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01569-1149
Mailing Address - Country:US
Mailing Address - Phone:508-714-9309
Mailing Address - Fax:
Practice Address - Street 1:107 ST ANDRE DR
Practice Address - Street 2:
Practice Address - City:UXBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01569-1149
Practice Address - Country:US
Practice Address - Phone:508-714-9309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health