Provider Demographics
NPI:1023395324
Name:COSTELLO, PATRICK (DOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PINE GLEN RD
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-2342
Mailing Address - Country:US
Mailing Address - Phone:215-696-3937
Mailing Address - Fax:
Practice Address - Street 1:125 PINE GLEN RD
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-2342
Practice Address - Country:US
Practice Address - Phone:215-696-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003572L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist