Basic Information
| Provider Information | |||||||||
| NPI: | 1104134709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTA MCCUTCHEON | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | M | ||||||||
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| OtherLastName: | COSTA | ||||||||
| OtherFirstName: | JEAN | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 WESTERN WAY | ||||||||
| Address2: | |||||||||
| City: | DUXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023324506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819342444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 39A INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023604868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088301444 | ||||||||
| FaxNumber: | 5088303655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.