Provider Demographics
NPI:1548825854
Name:COSTANZO, NICOLINA
Entity type:Individual
Prefix:
First Name:NICOLINA
Middle Name:
Last Name:COSTANZO
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 1:612 TULIP AVE REAR
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-3756
Mailing Address - Country:US
Mailing Address - Phone:516-456-4841
Mailing Address - Fax:
Practice Address - Street 1:50 W HAWTHORNE AVE FL 2
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6223
Practice Address - Country:US
Practice Address - Phone:516-456-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0952211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical