Provider Demographics
NPI:1285762856
Name:COSTA, TRACEE ARLENE (LMP)
Entity type:Individual
Prefix:MRS
First Name:TRACEE
Middle Name:ARLENE
Last Name:COSTA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1232
Mailing Address - Country:US
Mailing Address - Phone:360-377-0919
Mailing Address - Fax:360-405-1677
Practice Address - Street 1:911 ADELE RD.
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337
Practice Address - Country:US
Practice Address - Phone:360-377-3751
Practice Address - Fax:360-405-1677
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007715225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist