NPI 1003394479

Malissa Ann Costanzo, OWNER

Practitioner Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility Forest Lake, MN

Practice location

Address: 844 8th Ave SE, Forest Lake, MN 55025
Phone: (651) 272-5608
Mailing address: 844 8th Ave SE, Forest Lake, MN 55025-1642

Registered specialties (2)

Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility Primary

Residential Treatment Facilities Taxonomy 320900000X Licence 1094965-1-HCBS (MN)

Other Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities providers in Minnesota →

Foster Care Agency

Agencies Taxonomy 253J00000X Licence 1094965-1-HCBS (MN)

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Registry record

NPI: 1003394479
Entity type: Individual
Sex (as registered): Female
NPI issued: 30 Jul 2018
Record last updated: 1 Aug 2018

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.