Individual
MALISSA ANN COSTANZO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OWNER
Contact information
Practice address
844 8TH AVE SE, FOREST LAKE, MN 55025
(651) 272-5608
Mailing address
844 8TH AVE SE, FOREST LAKE, MN 55025-1642
(651) 272-5608
Taxonomy
Speciality
Code
Description
License number
State
253J00000X
Foster Care Agency
1094965-1-HCBS
MN
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
1094965-1-HCBS
MN
Other
Enumeration date
07/30/2018
Last updated
08/01/2018
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