Provider Demographics
NPI:1336968437
Name:ACOSTA, THANYA BEVERLY
Entity type:Individual
Prefix:
First Name:THANYA
Middle Name:BEVERLY
Last Name:ACOSTA
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 1:2017 LOMITA BLVD # 2251
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1701
Mailing Address - Country:US
Mailing Address - Phone:323-999-1326
Mailing Address - Fax:
Practice Address - Street 1:12440 FIRESTONE BLVD STE 3001
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4300
Practice Address - Country:US
Practice Address - Phone:562-450-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA600961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical