Basic Information
| Provider Information | |||||||||
| NPI: | 1467772988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | ISAIAS | ||||||||
| MiddleName: | L. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1262 SUTTON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302717144 | ||||||||
| FaxNumber: | 5302717144 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959456410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304779800 | ||||||||
| FaxNumber: | 5304779803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.