Provider Demographics
NPI:1164029344
Name:KELLEY COSTELLO, LMFT, INC.
Entity Type:Organization
Organization Name:KELLEY COSTELLO, LMFT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:774-322-1306
Mailing Address - Street 1:10 S MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2920
Mailing Address - Country:US
Mailing Address - Phone:774-322-1306
Mailing Address - Fax:
Practice Address - Street 1:10 S MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2920
Practice Address - Country:US
Practice Address - Phone:774-322-1306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty