Provider Demographics
NPI:1497885651
Name:COSTALES, SILVIA (MFT)
Entity type:Individual
Prefix:
First Name:SILVIA
Middle Name:
Last Name:COSTALES
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S MAIN ST # 203
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4261
Mailing Address - Country:US
Mailing Address - Phone:707-890-6022
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIN ST # 203
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4261
Practice Address - Country:US
Practice Address - Phone:707-890-6022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46421106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist