Provider Demographics
NPI:1023440138
Name:DAGOSTINO, COURTNEY FELICIA
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:FELICIA
Last Name:DAGOSTINO
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 1:2246 31ST ST
Mailing Address - Street 2:APT 3B
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2786
Mailing Address - Country:US
Mailing Address - Phone:518-567-1434
Mailing Address - Fax:
Practice Address - Street 1:2246 31ST ST
Practice Address - Street 2:APT 3B
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2786
Practice Address - Country:US
Practice Address - Phone:518-567-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2014-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713199131174400000X
NY590589121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist