IndividualActive
Malissa Costanzo, OWNER
NPI 1003394479 · Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility · Forest Lake, MN
Provider details
- NPI number
- 1003394479
- Entity type
- Individual
- Primary specialty
- Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityResidential Treatment Facilities
- Credential
- OWNER
- Sex
- Female
- Sole proprietor
- Yes
- License
- 1094965-1-HCBS (MN)
Mailing address
844 8th Ave Se
Forest Lake, MN 55025-1642
Registry dates
- Enumerated
- 2018-07-30
- Last updated
- 2018-08-01
Source: CMS NPPES Data Dissemination (June 2026). NPI Central is not affiliated with CMS. Data is provided as-is from the public registry.