Provider Information for 1477045979
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AMANDA RAE COSTA M.S.Ed Mental Health
Sex: Female
NPI: 1477045979
Last Updated: 2018-05-31
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1477045979 | ||||||||
| Enumeration Date | 2018-05-31 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 705 E KENSINGTON AVE SALT LAKE CITY, UT 84105-2224 United States Phone: 786-553-0488 | Fax: | ||||||||
| Primary Practice Address | 2200 S STATE ST SALT LAKE CITY, UT 84115-2724 United States Phone: 801-359-8862 | Fax: | ||||||||
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