Basic Information
| Provider Information | |||||||||
| NPI: | 1013979392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMHC LMFT LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 SPRING ST | ||||||||
| Address2: | STE 109 | ||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089961280 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 SPRING ST | ||||||||
| Address2: | STE 109 | ||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086780041 | ||||||||
| FaxNumber: | 5083249002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 103 | MA | X | Behavioral Health & Social Service Providers | Counselor | 104100000X | 202045 | MA | X | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | 129 | MA | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 103 | 01 | MA | LMHC LICENSE | OTHER | 129 | 01 | MA | LMFT LICENSE | OTHER | 202045 | 01 | MA | LCSW LICENSE | OTHER |