Provider Demographics
NPI:1124671763
Name:COSTA, AUDREY KAY (LCSW)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:KAY
Last Name:COSTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:APRIL
Other - Middle Name:KAY
Other - Last Name:LISIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:249 CLINTON CT
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-5138
Mailing Address - Country:US
Mailing Address - Phone:805-440-9503
Mailing Address - Fax:
Practice Address - Street 1:290 IOOF AVE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5204
Practice Address - Country:US
Practice Address - Phone:408-846-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW111480101YM0800X, 104100000X, 1041C0700X
CALCSW1114101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor