Provider Demographics
NPI:1316157134
Name:KOSTAKOS, EMANUEL (PHD)
Entity type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:
Last Name:KOSTAKOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 OLD TOWN RD APT 8J
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2216
Mailing Address - Country:US
Mailing Address - Phone:631-474-0901
Mailing Address - Fax:
Practice Address - Street 1:460 OLD TOWN RD APT 8J
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2216
Practice Address - Country:US
Practice Address - Phone:631-474-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010590-1103T00000X, 103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool