Provider Demographics
NPI:1528954039
Name:COSTA, AUDREY (LAC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BUDD LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07828-1913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11-13 SUNFLOWER AVE STE 1060
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3754
Practice Address - Country:US
Practice Address - Phone:201-485-6011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00875400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health