Provider Demographics
NPI:1952690901
Name:COSTA, CARY (DPT)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22821 LAKE FOREST DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1606
Mailing Address - Country:US
Mailing Address - Phone:949-716-5050
Mailing Address - Fax:949-482-2122
Practice Address - Street 1:22821 LAKE FOREST DR
Practice Address - Street 2:SUITE 115
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1606
Practice Address - Country:US
Practice Address - Phone:949-716-5050
Practice Address - Fax:949-482-2122
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT376712251X0800X
225100000X, 2251C2600X, 2251S0007X, 2251E1200X, 2251G0304X, 2251P0200X, 2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonary
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand