Provider Demographics
NPI:1609381060
Name:COSTAKIS, DOROTHY (LICDC, LISW-S)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:COSTAKIS
Suffix:
Gender:
Credentials:LICDC, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 ROCKY RIVER DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-4050
Mailing Address - Country:US
Mailing Address - Phone:216-954-0444
Mailing Address - Fax:
Practice Address - Street 1:3720 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4050
Practice Address - Country:US
Practice Address - Phone:216-954-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161501101YA0400X
OHI.2405225-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)