Provider Demographics
NPI:1194732487
Name:COSTANTINO, STEPHEN A (MPT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:COSTANTINO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 INDEPENDENCE WAY
Mailing Address - Street 2:SUITE 30204
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-2036
Mailing Address - Country:US
Mailing Address - Phone:401-536-4117
Mailing Address - Fax:401-943-2484
Practice Address - Street 1:75 INDEPENDENCE WAY
Practice Address - Street 2:SUITE 30204
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02921-2036
Practice Address - Country:US
Practice Address - Phone:401-536-4117
Practice Address - Fax:401-943-2484
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT017272251X0800X, 225100000X
MA18747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780672709OtherGROUP NPI#
0070106201Medicare PIN
1780672709OtherGROUP NPI#