1104915644 NPI number — MRS. HEATHER RENEE COSTAS MSPT, CIMT

Table of content: MRS. HEATHER RENEE COSTAS MSPT, CIMT (NPI 1104915644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104915644 NPI number — MRS. HEATHER RENEE COSTAS MSPT, CIMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTAS
Provider First Name:
HEATHER
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT, CIMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELANEY
Provider Other First Name:
HEATHER
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT, CIMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104915644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33900 HARPER AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48035-4258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-416-9100
Provider Business Mailing Address Fax Number:
528-416-9103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50174 SCHOENHERR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY TWP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48315-3136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-884-5040
Provider Business Practice Location Address Fax Number:
586-580-0375
Provider Enumeration Date:
10/12/2006

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: 225100000X , with the licence number:  5501011833 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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