Individual provider · Type 1 NPI
Malissa Ann Costanzo, OWNER
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility · Forest Lake, MN
Practice location
844 8th Ave SE
Forest Lake, MN 55025
Specialties and licenses
| Taxonomy | Code | License |
|---|---|---|
| Foster Care Agency | 253J00000X | 1094965-1-HCBS (MN) |
| Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility Primary | 320900000X | 1094965-1-HCBS (MN) |
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility: A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with intellectual and/or developmental disabilities.
About NPI 1003394479
Malissa Ann Costanzo, OWNER's National Provider Identifier is 1003394479, issued on Jul 30, 2018. The primary taxonomy on file is Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility (320900000X), and the practice location is in Forest Lake, MN. The record was last updated on Aug 1, 2018.