Provider Demographics
NPI:1932544368
Name:COSTON, BREYONNE MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:BREYONNE
Middle Name:MICHELLE
Last Name:COSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 SW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6912
Mailing Address - Country:US
Mailing Address - Phone:580-248-5780
Mailing Address - Fax:
Practice Address - Street 1:5717 NW LADY MARNA AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507
Practice Address - Country:US
Practice Address - Phone:580-574-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical