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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