Most Relevant Information
Provider Data
| NPI Number: | 1003394479 |
| Provider Name: | MALISSA ANN COSTANZO OWNER |
| Entity Type: | Individual |
| Taxonomy Code: | 253J00000X |
| Specialty: | Foster Care Agency |
| License Number: | 1094965-1-HCBS |
Most Important Dates
| Enumeration Date: | 07/30/2018 |
| Last Updated: | 08/01/2018 |
Provider Practice Location
844 8TH AVE SE
FOREST LAKE
MN
55025
Practice Location Phone/Fax
| Phone: | 6512725608 |
| Fax: |
Provider Mailing Location
844 8TH AVE SE
FOREST LAKE
MN
550251642
Provider Mailing Phone/Fax
| Phone: | 6512725608 |
| Fax: |