Provider Demographics
NPI:1982339925
Name:COSGROVE, JUSTIN KEVIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KEVIN
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 VILLA VALTELENA
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-0110
Mailing Address - Country:US
Mailing Address - Phone:424-215-7741
Mailing Address - Fax:
Practice Address - Street 1:1 RIDGEGATE DR STE 130
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5505
Practice Address - Country:US
Practice Address - Phone:951-694-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician