Provider Demographics
NPI:1164648341
Name:COSTON, CANDICE DENISE
Entity type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:DENISE
Last Name:COSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5827 THEODORE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-6010
Mailing Address - Country:US
Mailing Address - Phone:215-726-1509
Mailing Address - Fax:
Practice Address - Street 1:111 ELWYN RD
Practice Address - Street 2:
Practice Address - City:ELWYN
Practice Address - State:PA
Practice Address - Zip Code:19063-4622
Practice Address - Country:US
Practice Address - Phone:610-891-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist