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
State | License ID | Taxonomies |
---|---|---|
CA | PT37671 | 2251X0800X |
225100000X, 2251C2600X, 2251S0007X, 2251E1200X, 2251G0304X, 2251P0200X, 2251H1200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 2251C2600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Cardiopulmonary |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No | 2251E1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics |
No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |