Provider Demographics
NPI:1972256931
Name:COSTANZO, DANIELA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 GATES AVE APT 35
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:622 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2994
Practice Address - Country:US
Practice Address - Phone:973-380-0922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002827002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer