Basic Information
| Provider Information | |||||||||
| NPI: | 1801256490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RI-A1312301023 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ACOSTA | ||||||||
| OtherFirstName: | ALICE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RI-A1312301023 | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10511 MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906042440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629447953 | ||||||||
| FaxNumber: | 5629467494 | ||||||||
| Practice Location | |||||||||
| Address1: | 10511 MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906042440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629447953 | ||||||||
| FaxNumber: | 5629467494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2016 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RI-A1312301023 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | RI-A1312301023 | 01 | CA | BREINING | OTHER |