1871538017 NPI number — MS. ELLEN TERESA COSTILLA LISW

Table of content: MS. ELLEN TERESA COSTILLA LISW (NPI 1871538017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871538017 NPI number — MS. ELLEN TERESA COSTILLA LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTILLA
Provider First Name:
ELLEN
Provider Middle Name:
TERESA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871538017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 CARMEL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELEN
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87002-9200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-764-6409
Provider Business Mailing Address Fax Number:
505-764-6455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2741 INDIAN SCHOOL RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-2653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-255-8682
Provider Business Practice Location Address Fax Number:
505-255-7890
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I-04603 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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