Provider Demographics
NPI:1184333684
Name:COSTA, MICHELLE LEE (MA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:COSTA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SILO LN
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-8251
Mailing Address - Country:US
Mailing Address - Phone:401-602-5652
Mailing Address - Fax:
Practice Address - Street 1:1005 MAIN ST UNIT 715C
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-7802
Practice Address - Country:US
Practice Address - Phone:401-602-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RITAT02357225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist