Provider Demographics
NPI:1285071662
Name:COSTA, KIMBERLY (MSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:RODRIQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 W HUNT ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1619
Mailing Address - Country:US
Mailing Address - Phone:734-944-3446
Mailing Address - Fax:734-316-2093
Practice Address - Street 1:403 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2127
Practice Address - Country:US
Practice Address - Phone:734-944-3446
Practice Address - Fax:734-316-2093
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-27
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010935501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical