Provider Demographics
NPI:1083497127
Name:COSTELLO, CHRIS
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 ADDISON ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1533
Mailing Address - Country:US
Mailing Address - Phone:510-507-8568
Mailing Address - Fax:
Practice Address - Street 1:1819 ADDISON ST APT 4
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-1533
Practice Address - Country:US
Practice Address - Phone:510-507-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician