Provider Demographics
NPI:1063728830
Name:ACOSTA, MARIBEL (OTA)
Entity type:Individual
Prefix:MS
First Name:MARIBEL
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 24TH ST
Mailing Address - Street 2:12
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3933
Mailing Address - Country:US
Mailing Address - Phone:718-472-0887
Mailing Address - Fax:
Practice Address - Street 1:3925 24TH ST
Practice Address - Street 2:12
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3933
Practice Address - Country:US
Practice Address - Phone:718-472-0887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007687-1174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator