Basic Information
| Provider Information | |||||||||
| NPI: | 1043692221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTALES-EDGETT | ||||||||
| FirstName: | HAZEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE | ||||||||
| Address2: | STE D | ||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712242040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 825 S 94TH ST | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806303676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2015 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7554 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.