Provider Demographics
NPI:1164431136
Name:COSTELLO, CORINNA M (PHD, LPC, ATR-BC)
Entity Type:Individual
Prefix:DR
First Name:CORINNA
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHD, LPC, ATR-BC
Other - Prefix:
Other - First Name:CORI
Other - Middle Name:
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC, ATR-BC
Mailing Address - Street 1:10130 MALLARD CREEK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-6001
Mailing Address - Country:US
Mailing Address - Phone:980-257-1114
Mailing Address - Fax:
Practice Address - Street 1:10130 MALLARD CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6001
Practice Address - Country:US
Practice Address - Phone:980-257-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005808101YM0800X
NCS12959101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205799950OtherTAX ID
IL364073857OtherGROUP TAX ID. NUMBER