Provider Demographics
NPI:1124869268
Name:ACOSTA, CARLOS IVAN (MASTERS)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:IVAN
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 LISA LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-2039
Mailing Address - Country:US
Mailing Address - Phone:817-881-9804
Mailing Address - Fax:
Practice Address - Street 1:15851 DALLAS PKWY
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3369
Practice Address - Country:US
Practice Address - Phone:214-267-9556
Practice Address - Fax:833-457-1700
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94959101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional