Provider Demographics
NPI:1447615992
Name:COSTA GARDYN, CATHERINE (PMHNP-BC, ANP)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:COSTA GARDYN
Suffix:
Gender:F
Credentials:PMHNP-BC, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4610
Mailing Address - Country:US
Mailing Address - Phone:516-551-7112
Mailing Address - Fax:
Practice Address - Street 1:64 WOODCHUCK HOLLOW RD
Practice Address - Street 2:
Practice Address - City:COLD SPRING HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11724-2435
Practice Address - Country:US
Practice Address - Phone:516-551-7112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402096363LP0808X
NY306698363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health