Provider Demographics
NPI:1992338677
Name:ACOSTA, ANA GEORGINA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:GEORGINA
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 1:14213 SE CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2741
Mailing Address - Country:US
Mailing Address - Phone:971-712-8711
Mailing Address - Fax:
Practice Address - Street 1:912 NE KELLY AVE # 100C
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5629
Practice Address - Country:US
Practice Address - Phone:503-912-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst