Provider Demographics
NPI:1013408988
Name:COSTELLO, KATHLEEN M (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:S BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6432
Mailing Address - Country:US
Mailing Address - Phone:802-658-0040
Mailing Address - Fax:802-658-0216
Practice Address - Street 1:12 FAIRFIELD HILL RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9634
Practice Address - Country:US
Practice Address - Phone:802-524-1700
Practice Address - Fax:802-524-1777
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.00009411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical