Provider Demographics
NPI:1043361553
Name:COSTA, VIVIAN C
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:C
Last Name:COSTA
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 1:476 NAHUNTA RD NW
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27863-8651
Mailing Address - Country:US
Mailing Address - Phone:919-735-2101
Mailing Address - Fax:
Practice Address - Street 1:627 DEER ACRES DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-9238
Practice Address - Country:US
Practice Address - Phone:919-734-6649
Practice Address - Fax:919-734-6649
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC742462BMedicaid