Provider Demographics
NPI:1417787045
Name:ACOSTA, EMILY MARIE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
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 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:866-611-1558
Practice Address - Street 1:17325 N 75TH AVE
Practice Address - Street 2:17325 N 7TH AVE SUITE G-120
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303
Practice Address - Country:US
Practice Address - Phone:480-812-4789
Practice Address - Fax:602-610-4818
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBACB1059294106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician