Provider Demographics
NPI:1447375910
Name:COSTON, ELIZABETH CELINE (O,T)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CELINE
Last Name:COSTON
Suffix:
Gender:F
Credentials:O,T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 BOULEVARD SE APT B605
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-2328
Mailing Address - Country:US
Mailing Address - Phone:404-474-4723
Mailing Address - Fax:404-459-6566
Practice Address - Street 1:1123 OXFORD CRES NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1624
Practice Address - Country:US
Practice Address - Phone:404-247-7959
Practice Address - Fax:404-459-6566
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004491225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist