MALISSA ANN COSTANZO (NPI# 1003394479) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1003394479 |
| Entity Type | Individual |
| Full Name | MALISSA ANN COSTANZO |
| Credential | OWNER |
| Practice Address |
844 8th Ave Se Forest Lake MN 55025 |
| Mailing Address |
844 8th Ave Se Forest Lake MN 55025-1642 |
| Practice Telephone | 6512725608 |
| Mailing Telephone | 6512725608 |
| Enumeration Date | 2018-07-30 |
| Last Update Date | 2018-08-01 |
| Gender Code | F |
| Is Sole Proprietor | Y |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 320900000X | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 1094965-1-HCBS | MN | Residential Treatment Facilities |
| N | 253J00000X | Foster Care Agency | 1094965-1-HCBS | MN | Agencies |
| Street Address |
844 8TH AVE SE |
| City | FOREST LAKE |
| State | MN |
| Zip Code | 55025 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1043846173 | Persistence Physical Therapy LLC | Clinic/Center | 2009 W Broadway Ave, Ste 400 Pmb 131, Forest Lake, MN 55025 | 2020-03-20 |
| 1255973319 | Connie Rettig | Technician | 908 North Shore Drive, Forest Lake, MN 55025 | 2019-10-10 |
| 1669754735 | Brent Alan Millard | Pharmacist | 1207 West Broadway Ave, Forest Lake, MN 55025 | 2011-09-15 |
| 1982842167 | Lakes Center for Youth and Families | Community/Behavioral Health | 20 N Lake Street, Suite 103, Forest Lake, MN 55025 | 2009-01-27 |
| 1487843355 | Paul Luke Mladnick | Marriage & Family Therapist | 1068 So Lake St, #109, Forest Lake, MN 55025 | 2007-10-17 |
| 1740477678 | Rita Lynn Scanlan | Occupational Therapist | 604 Ne 1st St, Birchwood Health Care Center, Forest Lake, MN 55025 | 2007-09-25 |
| 1114053113 | Senior Care Forest Lake, LLC | Skilled Nursing Facility | 604 N.e. First Street, Forest Lake, MN 55025 | 2007-02-26 |
| 1073672101 | Catharine B Ruther | Dentist | 956 West Broadway, Lakes Dental Clinic, Forest Lake, MN 55025 | 2006-12-06 |
| 1407914849 | Ervin George Savord | Dentist | 255 Highway 97, Suite 1b, Forest Lake, MN 55025 | 2006-12-05 |
| 1609945286 | Elizabeth Anne Mcinerney | Social Worker | 882 Sw 15th Avenue, Forest Lake, MN 55025 | 2006-11-07 |
| Find all providers in zip 55025 | ||||
| Taxonomy Code | 320900000X |
| Grouping | Residential Treatment Facilities |
| Classification | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
| A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |
| Notes: [7/1/2003: new] |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1184244527 | Kam Homecare | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 1500 Nicollet Ave Apt 305, Minneapolis, MN 55403-2724 | 2020-04-24 |
| 1477117885 | Kelly Rae Martin | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 13881 Schuelke Beach Rd Nw, Miltona, MN 56354 | 2019-05-01 |
| 1295291573 | Tricia Bastian | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 607 4th St S, Walker, MN 56484-6400 | 2019-02-12 |
| 1881163632 | Jacob Wrich | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 603 3rd St W Apt 1, Hastings, MN 55033-1127 | 2018-11-21 |
| 1154814564 | Laurie K. Tazelaar-williams | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 5253 W Bald Eagle Blvd, White Bear Lake, MN 55110-6532 | 2018-06-11 |
| 1205340577 | Dale Conrad Forslin | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 1029 Highway 65 Ste 107, Braham, MN 55006-3360 | 2017-11-25 |
| 1952831026 | Noble Senior Center Inc | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 1094 University Ave W, Saint Paul, MN 55104 | 2017-06-12 |
| 1407396336 | Viko Health Services | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 5651 69th Ave N, 203, Brooklyn Park, MN 55429-1579 | 2017-02-25 |
| 1972052702 | Marie-noel Hiol-hiol | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 14642 Quartz Ter Nw, Ramsey, MN 55303-4581 | 2016-09-21 |
| 1750839569 | Kubra Residential Center | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 1711 W 143rd St Apt 120, Burnsville, MN 55306-7989 | 2016-09-21 |
| Find all providers with the same taxonomy | ||||
| City | FOREST LAKE |
| Zip Code | 55025 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.