Provider Demographics
NPI:1194113084
Name:COSTA, VINCENT (DR)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9212 SEAMILL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-8004
Mailing Address - Country:US
Mailing Address - Phone:704-779-2961
Mailing Address - Fax:
Practice Address - Street 1:2124 CROWN CENTRE DR STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7804
Practice Address - Country:US
Practice Address - Phone:704-849-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8321OtherLICENSED PROFESSIONAL COUNSELOR