Provider Demographics
NPI:1174399893
Name:ACOSTA, MYA MARIA
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:MARIA
Last Name:ACOSTA
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 1:3313 ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6714
Mailing Address - Country:US
Mailing Address - Phone:954-235-3520
Mailing Address - Fax:
Practice Address - Street 1:2300 CLEAR CREEK RD STE 103
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4985
Practice Address - Country:US
Practice Address - Phone:254-768-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB1021951106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician