Malissa Ann Costanzo, OWNER

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

1094965-1-HCBS Issued in MN

Practice address

844 8TH Ave SE
Forest Lake, MN 55025

Phone

(651) 272-5608

NPI assigned

Jul 30, 2018

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1532908800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1533081600000",
    "number": "1003394479",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "844 8TH AVE SE",
            "city": "FOREST LAKE",
            "state": "MN",
            "postal_code": "550251642",
            "telephone_number": "651-272-5608"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "844 8TH AVE SE",
            "city": "FOREST LAKE",
            "state": "MN",
            "postal_code": "55025",
            "telephone_number": "651-272-5608"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "COSTANZO",
        "first_name": "MALISSA",
        "middle_name": "ANN",
        "credential": "OWNER",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-07-30",
        "last_updated": "2018-08-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "253J00000X",
            "taxonomy_group": "",
            "desc": "Foster Care Agency",
            "state": "MN",
            "license": "1094965-1-HCBS",
            "primary": false
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "MN",
            "license": "1094965-1-HCBS",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Forest Lake, MN
• Providers in Forest Lake, MN by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.