Organization
COSTA CLINICAL PSYCHOLOGY, LLC
Active
Organization
COSTA CLINICAL PSYCHOLOGY, LLC
Active
Other names
Teresa I. Costa, PSYD
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TERESA IONE COSTA PSYD (CLINICAL PSYCHOLOGIST)
(541) 412-0700
Entity
Organization
Contact information
Practice address
625 SPRUCE ST., # 7666, BROOKINGS, OR 97415
(541) 412-0700
(541) 412-0711
Mailing address
625 SPRUCE ST., P.O. BOX 7666, BROOKINGS, OR 97415
(541) 412-0700
(541) 412-0711
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
2356
OR
1041C0700X
Clinical Social Worker
L6298
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500659667
—
OR
01
—
R16961
MEDICARE PTAN
OR
Enumeration date
10/11/2016
Last updated
10/11/2016
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