Provider Demographics
NPI:1073227054
Name:COSTELLO, CARMINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARMINE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 WINDY HILL RD SE UNIT 2084
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30081-3039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:385 HIGHTOWER TRAIL
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549
Practice Address - Country:US
Practice Address - Phone:770-731-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty