Provider Demographics
NPI:1194485169
Name:COSTANZA, SHAYE LYNN
Entity type:Individual
Prefix:
First Name:SHAYE
Middle Name:LYNN
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 S AUBURN ST STE C2
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4318
Mailing Address - Country:US
Mailing Address - Phone:530-265-5811
Mailing Address - Fax:
Practice Address - Street 1:760 S AUBURN ST STE C2
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4318
Practice Address - Country:US
Practice Address - Phone:530-265-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor