Provider Demographics
NPI:1770894461
Name:COSTA, TERESA IONE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:IONE
Last Name:COSTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7666
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0349
Mailing Address - Country:US
Mailing Address - Phone:541-412-0700
Mailing Address - Fax:541-412-0711
Practice Address - Street 1:217 MARINE DR
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-8297
Practice Address - Country:US
Practice Address - Phone:541-412-0700
Practice Address - Fax:541-412-0711
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2356103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500659667Medicaid
ORR16961Medicare PIN